Relationship Between Severity of Depression and Alcohol and/or Tobacco Use Among Adults with Type 2 Diabetes
Authors: Shaikh Nida I. , Poongothai Subramani , Ali Mohammad K. , Chwastiak Lydia , Mohan Viswanathan 
Published: November 2023

IntroductionSubstantial evidence in western settings support strong associations between current depression and increased risk of current smoking and alcohol use, even among patients with type 2 diabetes. Little is known about the nature of these associations in other settings including India.ObjectiveTo evaluate the relationship between severity of depression and alcohol and tobacco use among adults with type 2 diabetes in India.MethodsSubjects were 404 adults aged 35–74 years with depression and type 2 diabetes participating in the ongoing INTegrating DEPrEessioN and Diabetes TreatmENT (INDEPENDENT) trial aimed at testing the integration of a depression‐focused intervention into existing diabetes care in India. From the trial's administered survey at baseline, responses to PHQ‐9 (extent of depressive symptoms), AUDIT‐c (alcohol use in past year), tobacco use (smoking and/or chewable form), and demographic and socioeconomic characteristics were drawn and described. Depression severity was dichotomized as moderate and severe (PHQ‐9 score: 10–14 vs. 15–22), respectively. Alcohol consumers and non‐consumers were defined using AUDIT‐c scores (≥1 vs. 0), respectively. Students t test and chi‐square tests were used to describe characteristics of subjects according to depression severity status. Multivariate logistic regression was conducted to identify the relationship between alcohol and tobacco use (exposure as a single and/or dual habit) and severity of depression (outcome), adjusting for covariates.ResultsOverall, 75% had moderate depression and 25% had severe depression (PHQ‐9 range: 10–22, mean PHQ‐9 score: 12.1 ± 1.4 vs. 16.7 ± 1.7, p<0.001), 6.7% used alcohol in the past year, 6.7% smoked and/or chewed tobacco, and 2.7% used both alcohol and tobacco. Severity of depression was significantly associated with gender (severe depression: 69.3% female vs. 30.7% male; moderate depression: 55.8% female and 44.2% male) and marital status (p<0.05). Those with moderate depression had significantly (p<0.05) more members in the household (4.7 ± 2.9 vs. 4.0 ± 2.0), had been chewing tobacco longer (1.0 ± 5.4 years vs. 0.3 ± 1.7 years) and were taller (158.8 ± 8.9 cm vs. 156.2 ± 8.6 cm) than those with severe depression; who had significantly higher LDL cholesterol (109.4 ± 37.5 mg/dl vs. 98.0 ± 37.9 mg/dl, p<0.05). Holding all covariates constant, the odds of having severe depression than moderate depression was over 3 times higher among alcohol consumers than non‐consumers (OR 3.12, 95% CI: 1.05, 9.28), was 12% lower for the presence of each additional member in the household (OR 0.88, 95% CI: 0.77, 0.99), and was 3% lesser for each 1 mm Hg increase in systolic blood pressure (OR 0.97, 95% CI: 0.95, 0.99).ConclusionSeverity of depression was associated with use of alcohol but not tobacco (smoking and/or chewable form) among adults with type 2 diabetes in India.Support or Funding InformationThis project was supported by National Institutes of Health (NIH) Research Training Grant R25 TW009337, funded by the Fogarty International Center, the NIH Office of the Director, and the National Institute of Mental Health (NIMH R01 MH100390).
Characteristics of adults with moderate versus severe depression: the INDEPENDENT study (n=404)

Characteristic1
Overall (n=404)
Moderate depression2 (n=303)
Severe depression3 (n=101)

Age (years)
52.7 ± 8.6
52.5 ± 8.4
53.0 ± 9.1

Male, %
40.8
44.2
30.7*

Education, %

Literate
92.6
91.8
93.4

Illiterate
7.4
8.2
6.6

Occupation,4 %

Employed
40.8
35.6
46.4*

Not employed
59.2
64.4
53.6

Monthly household income (INR),5 %

Low (<30,000 INR or <449.1 USD)
77.5
79.3
75.5

High (>30,001 INR or >449.1 USD)
22.5
20.7
24.5

Marital status, %

Married
85.4
77.2
88.1**

Other (single/widowed/separated/divorced)
14.6
22.8
11.9

Number of household members
4.6 ± 2.7
4.7 ± 2.9
4.0 ± 2.0**

Height, cm
158.2 ± 8.6
158.8 ± 8.9
156.2 ± 8.6**

Weight, kg
67.7 ± 12.8
67.7 ± 12.3
67.6 ± 14.4

BMI
26.9 ± 4.7
26.7 ± 4.3
27.6 ± 5.6

Waist Circumference, cm
94.7 ± 12.3
94.4 ± 12.1
95.6 ± 13.0

HbAlc
9.1 ± 1.9
9.1 ± 2.0
9.2 ± 1.8

Fasting blood glucose mg/dl
182.0 ± 72.4
181.7 ± 72.9
183.0 ± 71.0

Triglycerides, mg/dl
160.8 ± 83.3
161.6 ± 88.4
158.3 ± 67.4

Total cholesterol, mg/dl
173.9 ± 44.1
171.6 ± 42.8
180.9 ± 47.5

HDL cholesterol, mg/dl
41.9 ± 11.8
41.8 ± 12.1
42.1 ± 10.7

LDL cholesterol, mg/dl
100.9 ± 38.1
98.0 ± 37.9
109.4 ± 37.5**

Systolic Blood Pressure (mm Hg)
132.2 ± 16.3
133.0 ± 15.8
129.8 ± 17.5

Diastolic Blood Pressure (mm Hg)
80.3 ± 10.1
80.2 ± 10.4
80.3 ± 9.4

Alcohol use in past year (AUDIT‐c score)
0.17 ± 0.7
0.14 ± 0.6
0.25 ± 1.0

Alcohol use, %
6.7
6.3
7.9

Tobacco use, smoking form, %
3.0
3.6
1.0

Years smoked tobacco
1.0 ± 5.4
1.1 ± 5.4
0.8 ± 5.3

Number of cigarettes smoked/day
0.4 ± 2.2
0.5 ± 2.4
0.2 ± 1.1

Tobacco use, chewable form, %
3.7
4.0
3.0

Years chewed tobacco
0.8 ± 4.8
1.0 ± 5.4
0.3 ± 1.7*

Number of tobacco products chewed/day
0.2 ± 1.2
0.1 ± 1.2
0.2 ± 1.2

Tobacco use (smoking and/or chewable form)
6.7
7.6
4.0

Alcohol and tobacco use, %
2.7
3.3
1.0

Drug use, %
0
0
0

PHQ‐9 score
13.2 ± 2.5
12.1 ± 1.4
16.7 ± 1.7***

Difficulty/severity of depression, %

Not difficult at all
41.1
40.6
42.6*

Somewhat difficult
52.5
54.8
45.5

Very difficult
6.4
4.6
11.9

p ≤ 0.05,
p ≤ 0.01,
p ≤ 0.001.
Mean ± SD. Baseline data from INDEPENDENT Study collected between 2015–2016.
Moderate depression was defined as PHQ‐9 score between 10–14.
Severe depression was defined as PHQ‐9 score between 15–22.
Occupation was defined as employed (including professionals and skilled, semi‐skilled, and unskilled workers) or not‐employed (including housewives and those that are retired or unemployed).
INR, Indian Rupees; USD, US Dollars. 1 USD=66.8 INR as of November 2016.

Multivariate logistic regression [OR and 95% CI] describing relationship between severity of depression and alcohol and/or tobacco use among adults: the INDEPENDENT study (n=404)

Variables
Model 1Outcome: DepressionExposure: Alcohol use
Model 1a [Model 1 adjusted only for age and gender]
Model 1b [Model 1 adjusted for all covariates]
Model 2Outcome: DepressionExposure: Tobacco use
Model 2a [Model 2 adjusted only for age and gender]
Model 2b [Model 2 adjusted for all covariates]
Model 3Outcome: DepressionExposures: Alcohol and Tobacco use
Model 3a [Model 3 adjusted only for age and gender]
Model 3b [Model 3 adjusted for all covariates]

Exposure(s)
Alcohol consumer

Yes
1.29 (0.55, 3.03)
2.20 (0.85, 5.64)
2.33 (0.85, 6.41)
‐
‐
‐
1.74 (0.68, 4.42)
2.86 (1.04, 7.88)*
3.12 (1.05, 9.28)*

No (ref)
1.0
1.0
1.0

1.0
1.0
1.0

Tobacco user

Yes
‐

0.50 (0.17, 1.48)
0.61 (0.20, 1.82)
0.59 (0.18, 1.92)
0.40 (0.12, 1.29)
0.43 (0.13, 1.39)
0.40 (0.12, 1.41)

No (ref)
‐
‐
‐
1.0
1.0
1.0
1.0
1.0
1.0

Covariates
Age group

35–54 years (ref)
‐
NS1
NS
‐
NS
NS
‐
NS
NS

55–74 years

Gender

Male
‐
0.48 (0.28, 0.81)**
NS
‐
0.58 (0.36, 0.94)*
NS
‐
0.49 (0.29, 0.82)*
NS

Female (ref)

1.0

1.0

1.0

Education

Literate
‐
‐
NS
‐
‐
NS
‐
‐
NS

Illiterate (ref)

Occupation

Employed
‐
‐
NS
‐
‐
NS
‐
‐
NS

Not‐employed (ref)

Monthly household income

High (≥30,000 INR)
‐
‐
NS
‐
‐
NS
‐
‐
NS

Low (<30,000 INR) (ref)

Marital status

Married
‐
‐
NS
‐
‐
NS
‐
‐
NS

Other (ref)

Number of members in the household
‐
‐
0.88 (0.78, 0.99)*
‐
‐
0.88 (0.78, 0.99)*
‐
‐
0.88 (0.77, 0.99)*

BMI
‐
‐
NS
‐
‐
NS
‐
‐
NS

Waist circumference, cm
‐
‐
NS
‐
‐
NS
‐
‐
NS

HbA1c
‐
‐
NS
‐
‐
NS
‐
‐
NS

Triglycerides, mg/dl
‐
‐
NS
‐
‐
NS
‐
‐
NS

Total cholesterol, mg/dl
‐
‐
NS
‐
‐
NS
‐
‐
NS

HDL cholesterol, mg/dl
‐
‐
NS
‐
‐
NS
‐
‐
NS

LDL cholesterol, mg/dl
‐
‐
NS
‐
‐
NS
‐
‐
NS

Systolic Mood pressure, mm Hg
‐
‐
0.98 (0.95, 0.99)*
‐
‐
0.97 (0.95, 0.99)*
‐
‐
0.97 (0.95, 0.99)*

Diastolic blood pressure, mm Hg
‐
‐
NS
‐
‐
NS
‐
‐
NS

p ≤ 0.05,
p ≤ 0.01,
*** p ≤ 0.001;
NS, not significant at p <0.05; IN, Indian Rupees; 1 USD=66.8 INR as of November 2016.