CORRELATION BETWEEN CARDIOMETABOLIC DISEASES AND DEPRESSION IN A PERUVIAN REFERENCE HOSPITAL

ABSTRACT

Introduction: A correlation has been reported between presence of cardio metabolic diseases and mental health problems, specially depression.

Objectives: To determine the correlation between cardio metabolic diseases and depressive symptomatology, evaluated by means of the PHQ-9 questionnaire, for patients attended in Internal Medicine Outpatient Clinics of the "Hospital Nacional Hipólito Unanue".

Methodology: observational/analytic/cross sectional study. A cardio metabolic disease was defined as the presence of diabetes mellitus, arterial hypertension, dyslipidemia, and/or obesity. The PHQ-9 questionnaire was used for evaluating symptoms suggesting depression. The crude/adjusted association was evaluated to potential confounders. For the multivariate analysis a Poisson´s regression model was used, aimed to find prevalence reasons with their relevant confidence intervals, at 95%. p<0,05 was deemed as statistically significant.

Results: 252 patients were included. 205 of them (81.4%) had cardio metabolic diseases; 181 of them (71.9%) had symptoms consistent with a degree of depression. Presence of cardio metabolic diseases was correlated with depressive symptoms, both in the crude analysis (CP 1.43; CI 95% 1.08-1.89; p=0.012), as well as in the adjusted analysis (AP 1.31; CI 95% 1.00-1.71; p=0.048). Additionally, a correlation between feminine sex and depressive symptomatology was reported (AP 1.35; CI 95% 1.11-1.63; p=0.002).

Conclusions: Presence of cardio metabolic diseases was correlated with the presence of depressive symptoms in patients attended in the Internal Medicine Outpatient Clinic. Addressing mental health must be an integral part of multidisciplinary management of patients with cardio metabolic diseases.

Key words: Depression, Diabetes Mellitus, Hypertension, Dyslipidemia, Obesity. (Source: DeCS BIREME).

INTRODUCTION

Non communicable diseases are the main cause of death all over the world. Every year nearly 41 million people die (equivalent to 71% of  deaths, all over the world); mostly made up of cardiovascular diseases and diabetes (17.9 million and 1.6 million, respectively) ¹. In Peru, cardio metabolic diseases have become one of the widest areas of research, thus becoming a national priority of research ². in Peruvian population, prevalence of diabetes mellitus, arterial hypertension, dyslipidemia and obesity are estimated in 7% ³, 23.7% ⁴, 11.6% ⁵, and 22.3% ⁶ respectively. These conditions are still being poorly diagnosed, treated and controlled, and have a strong correlation among themselves, thus favoring progression of complications ⁷.

A patient, when diagnosed with a chronic disease must face new situations in his/her life, such as take care of his/her health, avoid complications, and responsibly adapt himself/herself to a healthy life style he/she was not used to. Before this process of adjustments and changes, the patient may experience various reactions and feelings, and depression among them. This may be associated to self-care problems, functionality impairment, and difficulties in treatment adherence, thus leading to a poor control of the basal disease ⁸. Additionally, from a physio pathological point of view, in patients with depressive disorders, some hormonal, inflammatory disturbances and autonomous nervous system problems have been reported, which could influence on physio pathological mechanisms of cardiovascular diseases, such as insulin resistance, hypertension and even obesity ⁹.

Despite the importance of mental health in patients with chronic diseases, studies regarding frequency of depression in patients with cardio metabolic diseases are relatively few in LatAm and especially in Peru. The objective of this study is to determine the correlation between cardio metabolic diseases and depressive symptoms  in patients of Internal Medicine Outpatient Clinic of the “Hospital Nacional Hipólito Unanue”, during a period from October to December, 2019.

METHODOLOGY

This is an observational/analytic/cross sectional study. The population was made up of patients, older than 18 years who were attended in the Internal Medicine Outpatient Clinic of the “Hospital Nacional Hipólito Unanue” during a period from October to December, 2019. In order to find the sample size, the authors worked with the expected prevalences for depression, in general population, i.e. 16% 10; for population with cardio metabolic diseases, 34% 11–13. The latter was obtained from the combined prevalence of three relevant cardio metabolic diseases (diabetes mellitus, arterial hypertension and obesity). Considering a confidence level of 95%, and un statistical power of 80%, a sample size of 202 was obtained.

The inclusion criteria were: patients attended in the internal medicine outpatient and health cardio metabolic Clinics of the “Hospital Nacional Hipólito Unanue” who accepted to participate in this study, prior signature of an informed consent. The exclusion criteria were, denial to participate in this research, not understanding the questions of the questionnaire, to have some kind of cognitive disability hindering communication, and to have a psychiatric diagnosis/treatment, including depression.

The dependent variable was depression, defined with a score ?5, according to the PHQ-9 questionnaire ¹⁴. The independent variable was the presence of cardio metabolic diseases, defined as the presence of diabetes mellitus, arterial hypertension, dyslipidemia and/or obesity (BMI ? 30 kg/m2 ) ¹⁵. Non-controlled diabetes mellitus was considered for patients who did not have a basal diagnosis and reported a glucose level on empty stomach of >130mg/dL and an HbA1c > 7%, oran HbA1c > 8%, in elderly people ¹⁶. In turn, non-controlled arterial hypertension to those who did not have a basal diagnosis and arterial pressure record of ? 140/90 mmHg, ? 140/80 mmHg in those patients who additionally had diabetes mellitus, PAS < 140 or > 150 mmHg in elderly people¹⁷.

For collecting the data, prior to the questionnaire a record was applied. Age, gender, education level, and marital status of the patients were recorded. In turn, blood pressure was measured in millimeters of mercury, weight in kilograms, and size in meters for all patients. (The last two measurements were used to determine the Body Mass Index [BMI]). Presence of cardio metabolic diseases (diabetes mellitus, arterial hypertension, dyslipidemia, obesity) was confirmed in the diagnosis made by the attending physician on the clinical record. After the interview, the last laboratory values were collected (glucose on empty stomach, glycosylated hemoglobin, total cholesterol and triglycerides) in their clinical record, within the previous six months to the day of the interview. The Patient Health Questionnarie-9 (PHQ-9) was used as a screening instrument for depression. It has an official version for Peru¹⁴, and it was validated by the Mental Health Department (Dirección de Salud Mental) of the Ministry of Health, in Peru and by the National Health Institute¹⁸ (Instituto Nacional de Salud). Its Cronbach´s Alpha coefficient is 0.903 ¹⁹.

The data collected was registered in a data base, based on Microsoft Excel 365. The analysis was made by using the statistical pack STATA, version ¹⁶. For the descriptive analysis, the qualitative variables were presented as frequencies and percentages; the quantitative variables were presented with central tendency/dispersion measures, according to their distribution. For the bivariate analysis, in case of qualitative variables, the Chi square test was made. In case of quantitative variables, Student´s Test or Mann Whitney´s Test were used, according to the distribution of such variable. The multivariate analysis was made by means of the Poisson´s regression Model with robust variances. The reasons of crude prevalences (CP) and adjusted prevalence (AP) were obtained with their relevant confidence intervals, at 95%. A value of p, lower than 0.05 as statistically significant, was included.

The study was reviewed and approved by the Ethics Committee of the Faculty of Medicine, Universidad Ricardo Palma and by the Ethics Committee, of the Hospital Nacional Hipólito Unanue. The informed consent of all the participants was obtained, thus guaranteeing data confidentiality. This research meets all the ethical norms regarding the Declaration of Helsinki.

DISCUSSION

1. Organización Mundial de la Salud. Enfermedades no transmisibles [Internet]. Centro de prensa. 2018 [citado 31 de agosto de 2020]. Disponible en: https://www.who.int/es/news-room/fact-sheets/detail/noncommunicable-diseases
2. Resolución Ministerial N° 658-2019/MINSA - "Prioridades Nacionales de Investigación en Salud en Perú 2019-2023" [Internet]. Prioridades de Investigación en Salud - INSTITUTO NACIONAL DE SALUD. [citado 17 de septiembre de 2019]. Disponible en: https://web.ins.gob.pe/es/investigacion-en-salud/prioridaes-de-investigacion?fbclid=IwAR3jMjwmZsRsozHO2CdRHcUK1dqSfJWvFRqEJ1sU5CgdkkDt0GhBf-w74T8
3. Seclen SN, Rosas ME, Arias AJ, Huayta E, Medina CA. Prevalence of diabetes and impaired fasting glucose in Peru: report from PERUDIAB, a national urban population-based longitudinal study. BMJ Open Diabetes Res Care. 1 de octubre de 2015;3(1):e000110.
4. Segura Vega L, Agustí C. R, Ruiz Mori E. La hipertensión arterial en el Perú según el estudio TORNASOL II. Rev Peru Cardiol Lima. abril de 2011;37(1):19-27.
5. Schargrodsky H, Hernández-Hernández R, Champagne BM, Silva H, Vinueza R, Ayçaguer LCS, et al. CARMELA: Assessment of Cardiovascular Risk in Seven Latin American Cities. Am J Med. 1 de enero de 2008;121(1):58-65.
6. Encuesta Demográfica y de Salud Familiar. Perú: Enfermedades No Transmisibles Y Transmisibles, 2019 [Internet]. 2019 [citado 30 de junio de 2020]. Disponible en: https://proyectos.inei.gob.pe/endes/salud.asp
7. Rivero Truit FA, Pérez Rivero V, Rivero Truit FA, Pérez Rivero V. Intervención educativa para la prevención de complicaciones en pacientes con dislipidemia. Rev Médica Electrónica. diciembre de 2019;41(6):1354-66.
8. Devarajooh C, Chinna K. Depression, distress and self-efficacy: The impact on diabetes self-care practices. PLOS ONE. 31 de marzo de 2017;12(3):e0175096.
9. Dhar AK, Barton DA. Depression and the Link with Cardiovascular Disease. Front Psychiatry [Internet]. 2016 [citado 18 de septiembre de 2020];7. Disponible en: https://www.frontiersin.org/articles/10.3389/fpsyt.2016.00033/full
10. Martina Martha, Ara Miguel Angel, Gutiérrez César, Nolberto Violeta, Piscoya Julia. Depresión y factores asociados en la población peruana adulta mayor según la ENDES 2014-2015. An. Fac. med.  [Internet]. 2017  Oct [citado  2019  Sep  20]?;  78( 4 ): 393-397. Disponible en: http://www.scielo.org.pe/scielo.php?script=sci_arttext&pid=S1025-55832017000400004&lng=es.  http://dx.doi.org/10.15381/anales.v78i4.14259.
11. Garcia Moreno. Depresión y factores antropometricos en adulto mayor, estudio de costos de la obesidad: análisis de la encuesta de demografía y salud familiar 2018 [Internet]. Universidad Ricardo Palma; 2020 [citado 29 de julio de 2020]. Disponible en: http://repositorio.urp.edu.pe/handle/URP/2880
12. Villanueva Bejarano AJ, Pantani Romero FA, Rosas Matías JD. Frecuencia de depresión y ansiedad no diagnosticadas en pacientes con diabetes mellitus tipo 2 que acuden a la consulta externa de un hospital general de Lima, Perú [Internet]. 2019 [citado 12 de septiembre de 2019]. Disponible en: http://repositorio.upch.edu.pe/handle/upch/6409
13. Crispín-Trebejo B, Robles-Cuadros MC, Bernabé-Ortiz A. Association between depression and glycemic control among type 2 diabetes patients in Lima, Peru. Asia-Pac Psychiatry. diciembre de 2015;7(4):419-26.
14. Patient Health Questionnaire (PHQ) Screeners [Internet]. phqscreeners. [citado 20 de septiembre de 2019]. Disponible en: https://www.phqscreeners.com/select-screener/36
15. Organización Mundial de la Salud. Obesidad y sobrepeso [Internet]. Centro de prensa. 2020 [citado 12 de septiembre de 2019]. Disponible en:
    https://www.who.int/es/news-room/fact-sheets/detail/obesity-and-overweight
16. Resolución Ministerial N° 719-2015-MINSA - "Guía Práctica Clínica para el Diagnóstico, Tratamiento y Control de la Diabetes Mellitus Tipo 2, en el Primer Nivel de Atención" [Internet]. Normas legales. [citado 21 de julio de 2020]. Disponible en: https://www.gob.pe/institucion/minsa/normas-legales/193275-719-2015-minsa
17. Resolución Ministerial N° 031-2015-MINSA - "Guía de Práctica Clínica para el Diagnóstico, Tratamiento y Control de la Enfermedad Hipertensiva" [Internet]. Normas legales. [citado 21 de julio de 2020]. Disponible en: https://www.gob.pe/institucion/minsa/normas-legales/195692-031-2015-minsa
18. Calderón M, Gálvez-Buccollini JA, Cueva G, Ordoñez C, Bromley C, Fiestas F. Validación de la versión peruana del PHQ-9 para el diagóstico de depresión. Rev Peru Med Exp Salud Pública [Internet]. 6 de febrero de 2014 [citado 19 de septiembre de 2019];29(4). Disponible en: https://rpmesp.ins.gob.pe/index.php/rpmesp/article/view/409
    
19. Huarcaya-Victoria J, De-Lama-Morán R, Quiros M, Bazán J, López K, Lora D. Propiedades psicométricas del Patient Health Questionnaire (PHQ-9) en estudiantes de medicina en Lima, Perú. Rev Neuropsiquiatr. 15 de julio de 2020;83(2):72-8.
20. Sharif S, Raza MT, Mushtaq S, Afreen B, Hashmi BA, Ali MH. Frequency of Depression in Patients with Type 2 Diabetes Mellitus and its Relationship with Glycemic Control and Diabetic Microvascular Complications. Cureus. 16 de julio de 2019;11(7):e5145.
21. Paredes-Arturo YV, Aguirre-Acevedo DC. Síntomas depresivos y factores asociados en población adulto mayor. Rev Mex Neurocienc. 15 de noviembre de 2016;17(3):26-38.
22. Jihoon Andrew K, Choi S, Choi D, Sang Min P. Pre-existing Depression among Newly Diagnosed Dyslipidemia Patients and Cardiovascular Disease Risk. Diabetes Metab J. abril de 2020;44(2):307-15.
23. Dehesh T, Dehesh P, Shojaei S. Prevalence and Associated Factors of Anxiety and Depression Among Patients with Type 2 Diabetes in Kerman, Southern Iran. Diabetes Metab Syndr Obes Targets Ther. 2020;13:1509-17.
24. Cardenas V, Mausbach BT, Sommerfeld D, Jimenez D, von Känel R, Ho JS, et al. Depression is Associated with Increased Risk for Metabolic Syndrome in Latinos with Type 2 Diabetes. Am J Geriatr Psychiatry Off J Am Assoc Geriatr Psychiatry. junio de 2017;25(6):646-53.
25. Haregu TN, Lee JT, Oldenburg B, Armstrong G. Comorbid Depression and Obesity: Correlates and Synergistic Association With Noncommunicable Diseases Among Australian Men. Prev Chronic Dis [Internet]. 2 de julio de 2020 [citado 31 de julio de 2020];17. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7367080/
26. Garg R, Saxena SK, Bashir S. Is obesity a risk to depression? A cross-sectional study. Ind Psychiatry J. junio de 2019;28(1):130-4.
27. De la Cruz-Mitac CYCDL, Quispe-Ilanzo MP, Oyola-García AE, Portugal-Medrano MÁ, Lizarzaburu-Córdova EE, Rodríguez-Chacaltana FW, et al. Depresión en adultos mayores con enfermedades crónicas en un hospital general del Perú*. Rev Cuerpo Méd HNAAA. 2017;10(4):205-11.
28. Alzahrani A, Alghamdi A, Alqarni T, Alshareef R, Alzahrani A. Prevalence and predictors of depression, anxiety, and stress symptoms among patients with type II diabetes attending primary healthcare centers in the western region of Saudi Arabia: a cross-sectional study. Int J Ment Health Syst [Internet]. 16 de julio de 2019 [citado 7 de septiembre de 2019];13. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6631923/
29. Constantino-Cerna A, Malca MB-, León-Jiménez F, Díaz-Vélez C. Frecuencia de depresión y ansiedad en pacientes con diabetes tipo 2 atendidos en un hospital general de Chiclayo. Rev Medica Hered. 18 de diciembre de 2014;25(4):196.
30. Organización Mundial de la Salud. Depresión [Internet]. Centro de prensa. 2020 [citado 1 de agosto de 2020]. Disponible en: https://www.who.int/es/news-room/fact-sheets/detail/depression

REFERENCES

1. Organización Mundial de la Salud. Enfermedades no transmisibles [Internet]. Centro de prensa. 2018 [citado 31 de agosto de 2020]. Disponible en: https://www.who.int/es/news-room/fact-sheets/detail/noncommunicable-diseases
2. Resolución Ministerial N° 658-2019/MINSA - "Prioridades Nacionales de Investigación en Salud en Perú 2019-2023" [Internet]. Prioridades de Investigación en Salud - INSTITUTO NACIONAL DE SALUD. [citado 17 de septiembre de 2019]. Disponible en: https://web.ins.gob.pe/es/investigacion-en-salud/prioridaes-de-investigacion?fbclid=IwAR3jMjwmZsRsozHO2CdRHcUK1dqSfJWvFRqEJ1sU5CgdkkDt0GhBf-w74T8
3. Seclen SN, Rosas ME, Arias AJ, Huayta E, Medina CA. Prevalence of diabetes and impaired fasting glucose in Peru: report from PERUDIAB, a national urban population-based longitudinal study. BMJ Open Diabetes Res Care. 1 de octubre de 2015;3(1):e000110.
4. Segura Vega L, Agustí C. R, Ruiz Mori E. La hipertensión arterial en el Perú según el estudio TORNASOL II. Rev Peru Cardiol Lima. abril de 2011;37(1):19-27.
5. Schargrodsky H, Hernández-Hernández R, Champagne BM, Silva H, Vinueza R, Ayçaguer LCS, et al. CARMELA: Assessment of Cardiovascular Risk in Seven Latin American Cities. Am J Med. 1 de enero de 2008;121(1):58-65.
6. Encuesta Demográfica y de Salud Familiar. Perú: Enfermedades No Transmisibles Y Transmisibles, 2019 [Internet]. 2019 [citado 30 de junio de 2020]. Disponible en: https://proyectos.inei.gob.pe/endes/salud.asp
7. Rivero Truit FA, Pérez Rivero V, Rivero Truit FA, Pérez Rivero V. Intervención educativa para la prevención de complicaciones en pacientes con dislipidemia. Rev Médica Electrónica. diciembre de 2019;41(6):1354-66.
8. Devarajooh C, Chinna K. Depression, distress and self-efficacy: The impact on diabetes self-care practices. PLOS ONE. 31 de marzo de 2017;12(3):e0175096.
9. Dhar AK, Barton DA. Depression and the Link with Cardiovascular Disease. Front Psychiatry [Internet]. 2016 [citado 18 de septiembre de 2020];7. Disponible en: https://www.frontiersin.org/articles/10.3389/fpsyt.2016.00033/full
10. Martina Martha, Ara Miguel Angel, Gutiérrez César, Nolberto Violeta, Piscoya Julia. Depresión y factores asociados en la población peruana adulta mayor según la ENDES 2014-2015. An. Fac. med.  [Internet]. 2017  Oct [citado  2019  Sep  20]?;  78( 4 ): 393-397. Disponible en: http://www.scielo.org.pe/scielo.php?script=sci_arttext&pid=S1025-55832017000400004&lng=es.  http://dx.doi.org/10.15381/anales.v78i4.14259.
11. Garcia Moreno. Depresión y factores antropometricos en adulto mayor, estudio de costos de la obesidad: análisis de la encuesta de demografía y salud familiar 2018 [Internet]. Universidad Ricardo Palma; 2020 [citado 29 de julio de 2020]. Disponible en: http://repositorio.urp.edu.pe/handle/URP/2880
12. Villanueva Bejarano AJ, Pantani Romero FA, Rosas Matías JD. Frecuencia de depresión y ansiedad no diagnosticadas en pacientes con diabetes mellitus tipo 2 que acuden a la consulta externa de un hospital general de Lima, Perú [Internet]. 2019 [citado 12 de septiembre de 2019]. Disponible en: http://repositorio.upch.edu.pe/handle/upch/6409
13. Crispín-Trebejo B, Robles-Cuadros MC, Bernabé-Ortiz A. Association between depression and glycemic control among type 2 diabetes patients in Lima, Peru. Asia-Pac Psychiatry. diciembre de 2015;7(4):419-26.
14. Patient Health Questionnaire (PHQ) Screeners [Internet]. phqscreeners. [citado 20 de septiembre de 2019]. Disponible en: https://www.phqscreeners.com/select-screener/36
15. Organización Mundial de la Salud. Obesidad y sobrepeso [Internet]. Centro de prensa. 2020 [citado 12 de septiembre de 2019]. Disponible en:
    https://www.who.int/es/news-room/fact-sheets/detail/obesity-and-overweight
16. Resolución Ministerial N° 719-2015-MINSA - "Guía Práctica Clínica para el Diagnóstico, Tratamiento y Control de la Diabetes Mellitus Tipo 2, en el Primer Nivel de Atención" [Internet]. Normas legales. [citado 21 de julio de 2020]. Disponible en: https://www.gob.pe/institucion/minsa/normas-legales/193275-719-2015-minsa
17. Resolución Ministerial N° 031-2015-MINSA - "Guía de Práctica Clínica para el Diagnóstico, Tratamiento y Control de la Enfermedad Hipertensiva" [Internet]. Normas legales. [citado 21 de julio de 2020]. Disponible en: https://www.gob.pe/institucion/minsa/normas-legales/195692-031-2015-minsa
18. Calderón M, Gálvez-Buccollini JA, Cueva G, Ordoñez C, Bromley C, Fiestas F. Validación de la versión peruana del PHQ-9 para el diagóstico de depresión. Rev Peru Med Exp Salud Pública [Internet]. 6 de febrero de 2014 [citado 19 de septiembre de 2019];29(4). Disponible en: https://rpmesp.ins.gob.pe/index.php/rpmesp/article/view/409
    
19. Huarcaya-Victoria J, De-Lama-Morán R, Quiros M, Bazán J, López K, Lora D. Propiedades psicométricas del Patient Health Questionnaire (PHQ-9) en estudiantes de medicina en Lima, Perú. Rev Neuropsiquiatr. 15 de julio de 2020;83(2):72-8.
20. Sharif S, Raza MT, Mushtaq S, Afreen B, Hashmi BA, Ali MH. Frequency of Depression in Patients with Type 2 Diabetes Mellitus and its Relationship with Glycemic Control and Diabetic Microvascular Complications. Cureus. 16 de julio de 2019;11(7):e5145.
21. Paredes-Arturo YV, Aguirre-Acevedo DC. Síntomas depresivos y factores asociados en población adulto mayor. Rev Mex Neurocienc. 15 de noviembre de 2016;17(3):26-38.
22. Jihoon Andrew K, Choi S, Choi D, Sang Min P. Pre-existing Depression among Newly Diagnosed Dyslipidemia Patients and Cardiovascular Disease Risk. Diabetes Metab J. abril de 2020;44(2):307-15.
23. Dehesh T, Dehesh P, Shojaei S. Prevalence and Associated Factors of Anxiety and Depression Among Patients with Type 2 Diabetes in Kerman, Southern Iran. Diabetes Metab Syndr Obes Targets Ther. 2020;13:1509-17.
24. Cardenas V, Mausbach BT, Sommerfeld D, Jimenez D, von Känel R, Ho JS, et al. Depression is Associated with Increased Risk for Metabolic Syndrome in Latinos with Type 2 Diabetes. Am J Geriatr Psychiatry Off J Am Assoc Geriatr Psychiatry. junio de 2017;25(6):646-53.
25. Haregu TN, Lee JT, Oldenburg B, Armstrong G. Comorbid Depression and Obesity: Correlates and Synergistic Association With Noncommunicable Diseases Among Australian Men. Prev Chronic Dis [Internet]. 2 de julio de 2020 [citado 31 de julio de 2020];17. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7367080/
26. Garg R, Saxena SK, Bashir S. Is obesity a risk to depression? A cross-sectional study. Ind Psychiatry J. junio de 2019;28(1):130-4.
27. De la Cruz-Mitac CYCDL, Quispe-Ilanzo MP, Oyola-García AE, Portugal-Medrano MÁ, Lizarzaburu-Córdova EE, Rodríguez-Chacaltana FW, et al. Depresión en adultos mayores con enfermedades crónicas en un hospital general del Perú*. Rev Cuerpo Méd HNAAA. 2017;10(4):205-11.
28. Alzahrani A, Alghamdi A, Alqarni T, Alshareef R, Alzahrani A. Prevalence and predictors of depression, anxiety, and stress symptoms among patients with type II diabetes attending primary healthcare centers in the western region of Saudi Arabia: a cross-sectional study. Int J Ment Health Syst [Internet]. 16 de julio de 2019 [citado 7 de septiembre de 2019];13. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6631923/
29. Constantino-Cerna A, Malca MB-, León-Jiménez F, Díaz-Vélez C. Frecuencia de depresión y ansiedad en pacientes con diabetes tipo 2 atendidos en un hospital general de Chiclayo. Rev Medica Hered. 18 de diciembre de 2014;25(4):196.
30. Organización Mundial de la Salud. Depresión [Internet]. Centro de prensa. 2020 [citado 1 de agosto de 2020]. Disponible en: https://www.who.int/es/news-room/fact-sheets/detail/depression