Abstract
Background
Diabetes is a prevalent chronic condition that has been linked to depression and suicidal behavior. The Aboriginal peoples of Canada are known to suffer from significant health disparities and higher burden of physical and mental illnesses. The purpose of this study was to assess whether diabetes is associated with higher depressive symptoms and lifetime suicidal ideation among Aboriginal Canadian peoples living off-reserve.
Methods
Data were obtained from the Aboriginal Peoples Survey, 2012. Depressive symptoms were evaluated by a modified version of the previously validated K-10 scale, while diabetes and suicidal ideation were self-reported. A secondary analysis was conducted on a weighted sample of 689,860 participants for depressive symptoms (9.25% diabetics) and 694,960 for suicidal ideation (9.39% diabetics). Descriptive statistics and multiple logistic regression analysis were conducted.
Results
Our study found that the prevalence of depressive symptoms was higher among diabetics (17.53%) compared with nondiabetics (11.12%; OR =1.70, 95% CI: 1.22–1.61). After adjusting for sociodemographic variables, smoking/alcohol use/drug use, anxiety disorders, and other chronic illnesses, diabetes was still significantly associated with depressive symptoms (aOR =1.46, 95% CI: 1.03–2.07). Additionally, diabetics (23.86%) were more likely to report suicidal ideation compared with nondiabetics (18.71%; OR =1.36, 95% CI: 1.05–1.77). Controlling for the effect of sociodemographics and health-related behaviors, diabetes was still associated with higher risk of reporting suicidal ideation (aOR =1.40, 95% CI: 1.05–1.88).
Conclusion
Our results suggest that the Aboriginal Canadian diabetic patients living off-reserve are at higher risk of depressive symptoms and suicidal ideation. Culturally appropriate co-screening strategies need to be implemented in primary health care settings to provide the supports necessary for this vulnerable population. Further research is needed to fully elucidate the nature of these associations in order to develop effective intervention and treatment approaches.
Introduction
Aboriginal peoples constitute diverse groups of the original inhabitants of Canada and their descendants. According to the Canadian constitution, three major groups are recognized: First Nations, Inuit, and Métis.Citation1 In 2016, there were ~1.7 million Aboriginal peoples, representing 4.9% of the Canadian population. They represent one of the youngest and fastest growing subsegments of the Canadian population.Citation2 The Aboriginal Canadian peoples have consistently shown high rates of diabetes, depression, and suicidal behavior.Citation3–Citation5 In general, diabetes has been linked to both depression and suicidal behavior.Citation6,Citation7 However, research that specifically examines the association between diabetes, depression, and suicidal behavior among Aboriginal Canadian peoples is lacking.
The Aboriginal Canadian peoples endure significant health disparities that lead to a higher burden of diseases compared with their non-Aboriginal counterparts.Citation8,Citation9 These health disparities are a by-product of socioeconomic, cultural, and political factors that negatively impact Aboriginal peoples. The socioeconomic disadvantages stem from lower levels of education and income, higher unemployment rates, and poor housing conditions.Citation9 The political inequities emerged as a consequence of colonization and resulted in the undermining of indigenous cultures and values, marginalization, and social exclusion.Citation10 For instance, the historical trauma caused residential schools, which were established by the Canadian government to assimilate Aboriginal children into Euro-Canadian culture, had a wide impact and serious ramifications on the Aboriginal survivors and their descendants.Citation10 The persistence and growth of these inequities ultimately resulted in health disparities including poor physical and mental health among Aboriginal peoples.Citation10
Aboriginal peoples are particularly vulnerable and disproportionally affected by diabetes in Canada.Citation11 Diabetes, once considered rare among Aboriginal communities, is now reported at higher rates among First Nations living off-reserve (10.3%) and among Métis (7.3%) compared with the general Canadian population (5%), and the gap is increasing.Citation12 Even among Inuit people, who historically have reported very low rates of diabetes, the trends are changing as their rates are becoming comparable to the general population (4.3%). These findings are mainly due to poor dietary choices, limited physical activity, and increased obesity.Citation13,Citation14 Aboriginal individuals are more likely to be diagnosed with diabetes at a younger age, suffer from serious complications, and experience worse treatment outcomes compared with non-Aboriginals.Citation15 Moreover, underreporting of the disease and limited access to health care services continue to be growing concerns for the Canadian Aboriginal peoples,Citation16 suggesting the magnitude of the diabetic epidemic may be larger than estimated.Citation17
Depression is a common comorbidity with diabetes.Citation6,Citation18,Citation19 Diabetic depressed patients are less likely to adhere to medical treatment and lifestyle changes, resulting in poor prognosis for both conditions.Citation20 This comorbidity has been widely examined in different populations but there is scarcity of research among Aboriginal peoples. It is known that Aboriginal peoples of Australia face health disparities that are similar to the Aboriginal peoples of Canada.Citation21 A study in Australia evaluated the prevalence of depression among urban diabetic patients and found it to be two times greater among the Aboriginal compared with the non-Aboriginal population.Citation23 The authors further reported that among Aboriginal individuals, depression tended to be more severe in nature and in many cases, undiagnosed and left untreated.Citation22
Aboriginal Canadian populations have one of the highest rates of suicide worldwide.Citation23 Among the First Nations, suicide rates are two times the national average and alarmingly, the Inuit suicide rates are among the highest in the world (6–11 times the national average).Citation4 Suicidal ideation is a crucial component of suicidal behavior, which often precedes suicidal attempts or completed suicide, and is known to be a strong predictor for suicidal death.Citation24 In 2012, 24% of First Nations living off-reserve, 23.5% of Inuit, and 19.6% of Métis people reported lifetime suicidal ideation compared with 11.1% in the general Canadian population.Citation25 Similar to depression, suicidal behavior has been linked to diabetes. However, the scientific evidence is limited and at times, contradictory,Citation7,Citation26 and therefore, more research is needed in this area.
Despite Aboriginal peoples in Canada consistently reporting higher prevalence of diabetes, depression, and suicidality, to the best of our knowledge, no studies explored the associations between these conditions among this vulnerable population. Therefore, the aim of the present study was to use data from the Aboriginal Peoples Survey (APS), 2012, to 1) determine the prevalence of depressive symptoms and suicidal ideation among patients with diabetes; 2) investigate whether diabetes is associated with a higher risk of depression and suicidal ideation; and 3) assess whether these associations vary by different characteristics among the Aboriginal Canadian populations living off-reserve.
Methods
Study characteristics
Design
Cross-sectional population-based observational study.
Participants
The Indian reserve system is governed by the Indian Act (1876) and relates to the First Nations people of Canada. Historically, First Nations people were legally bound by the Canadian government to live on reserve. The ban was lifted in 1951 and First Nations were allowed to live on- or off-reserve.Citation27 Presently, the majority (62%) of the First Nations population live off-reserve, while the remaining portion (38%) live on-reserve.Citation28 Métis and Inuit people traditionally do not live on-reserves. In this study, we are examining the off-reserve Aboriginal population (First Nations, Métis, and Inuit).
Data source
The present study used data from the APS conducted by Statistics Canada in 2012. It is a national survey on the social and economic conditions of First Nations living off-reserve, Métis, and Inuit. The total weighted number of participants in the APS is 9,63,110 with a participation rate of 76% and used stratification-specific domains for sampling.Citation29 For this study, the age of participants ranged between 15 and 97 years old. To ensure that statistical estimates would be representative of the Aboriginal Canadian population, sampling weights computed by Statistics Canada were incorporated into the analysis, and the Taylor linearization method was used to estimate the covariance matrix of the regression coefficients (SURVEYLOGISTIC procedure in SAS).
Measures
Measuring tool
Evaluation of depressive symptoms in this study was based on the use of a modified version of the previously validated K-10 distress scale.Citation30,Citation31 The K-10 scale is used to evaluate the distress experienced by individuals during the past 30 days.Citation32 The K-10 scale and a number of its modified versions (K-5, K-6) have been previously used among Aboriginal peoples.Citation33,Citation34 While these tools measure distress rather than depression or anxiety, their scores correlate well with depression and anxiety.Citation30–Citation32 Self-reported suicidal ideation was part of the APS questionnaire.
Outcome measures
The main outcome measures for this study were depressive symptoms and lifetime suicidal ideation.
Depressive symptoms
The present study used a modified version of the K-10 scale to assess depressive symptoms among Aboriginal participants. Six questions were selected, which addressed components of two domains that included core symptoms (depressed mood and reduced energy) and associated symptoms (unworthiness and hopelessness).Citation35 These questions were as follow: “In the past 4 weeks, about how often did you feel: 1) tired out for no good reason, 2) hopeless, 3) depressed, 4) everything was an effort, 5) sad that nothing could cheer you up, and 6) worthless?” Responses were ranked on a Likert scale: 1) all of the time, 2) most of the time, 3) some of the time, 4) a little of the time, and 5) none of the time. To assess the reliability of these questions, Cronbach’s α was calculated and found to be satisfactory (0.837). A mean score for each respondent was calculated and adjusted for the number of questions answered. Participants were dichotomized on the basis of a recommended cutoff value from the K-10 scale. Those who scored ≥2.5 were considered “depressed” while those with scores <2.5 were “not depressed”.Citation36
Suicidal ideation
Lifetime suicidal ideation was assessed by asking the following question: “Have you ever seriously considered committing suicide or taking your own life?” The answer was either “yes” or “no”.
Exposure variable
The main exposure variable was self-reported diabetes status. Diabetics were those respondents, who answered “yes” to the following question: “We are interested in conditions diagnosed by a health professional and that are expected to last or have already lasted 6-months or more. Do you have diabetes?”
Control variables (covariates)
In the present study, sociodemographic, health-related behavior, and clinical profile variables were used as controls in our logistic regression models. Selection of these variables was based on the recommendations made in the existing scientific literature.Citation37
Sociodemographic variables
These included, age (≤19, 20–34, 35–54,≥55 years old), sex (male or female), marital status (single, married, widowed/separated/divorced, living in common law), Aboriginal identity (First Nations, Métis, Inuit), highest level of education attained – 1) grade 8 or lower/some secondary education; 2) secondary school diploma/some postsecondary education; 3) postsecondary certificate or diploma below bachelor level; and 4) bachelor’s degree/university certificate or diploma or degree above bachelor level.
Health-related behavior variables
These included the smoking status (daily, occasional, nonsmoker), alcohol use (regular, occasional, nondrinker), and drug use (yes, no).
Clinical profile variables
These included chronic illnesses – a derived variable that combined responders who answered “yes” to one of the following questions: “Do you have asthma, fibromyalgia, learning disability, attention deficit disorder, chronic bronchitis, emphysema, chronic obstructive pulmonary disease (COPD), intestinal or stomach ulcers, bowel disorder, hypertension, heart disease and other physical or mental disorders and anxiety disorders (assessed using the following question: ‘Do you have an anxiety disorder such as a phobia, obsessive-compulsive disorder or a panic disorder?’ [yes, no].)” Additionally, for suicidal ideation, mood disorders were included (as a covariate based on the question: “Do you have a mood disorder such as depression, bipolar disorder, mania or dysthymia?” [yes, no]).
Statistical analysis
Initially, cross tabulations were performed examining the distribution of observations by depressive symptoms, and suicidal ideation status for each variable. Results are reported as rounded weighted frequencies in order to comply with the Statistics Canada requirements for data release and dissemination. The unadjusted association between diabetes and other covariates on depressive symptoms and suicidal ideation were calculated using univariate binary logistic regression models. Covariates with a P-value <0.25 were qualified to be included in the multivariable logistic regression models.
For each outcome, four logistic regression models were constructed: Model 1 (crude unadjusted associations between exposure and outcome variable), Model 2 (adjusted for the effect of sociodemographic confounders), Model 3 (additionally adjusted for health-related behavior), and Model 4 (additionally adjusted for clinical profile variables). If the P-value for a covariate was <0.05, the variable was retained in the multivariable model. Age and gender were considered important confounders, and therefore, adjusted in the model irrespective of their P-values. The Akaike Information Criterion (AIC) comparisons were used to compare the models (lower is better).
Confounders and interaction assessment
To assess whether a covariate had a confounding effect, a change of 20% or more in the coefficient of the main exposure variable (diabetes) was used as a cutoff.Citation38 Effect modifications were investigated by examining all possible two-way interactions for the main exposure variable (diabetes) with predictors and confounders included in the main effect model. Interactions were assessed based on their P-value and AIC comparisons.
Model diagnostics
The variance inflation factor (VIF) and tolerance for all variables were calculated to assess whether multicollinearity (if present) would significantly affect reported estimates. We used a cutoff at 2.5 for VIF and 0.4 for tolerance.Citation39 For model predictability, the receiver operating characteristic curve was generated and the area under the curve was measured and reported. All statistical analyses were performed using SAS V.9.4 (SAS Institute Inc., Cary, NC, USA). To deal with missing values, NOMCAR command was used for data analysis with SURVEYLOGISTIC. NOMCAR (not missing completely at random) suggests that missing data are not randomly missed and computes variance accordingly. This ensures that despite the missing data, the full structure of the complex sample is accurately reflected in the calculated estimates.Citation40
Results
Depressive symptoms
The total number of Aboriginal participants who responded to the depression questions was 6,89,860. Of these participants, 11.65% (n=80,350) were classified as having depressive symptoms. The prevalence of depressive symptoms among those who reported a physician diagnosis of diabetes was 17.53% (n=11,100), compared to 11.12% (n=69,070) among the nondiabetic participants. depicts the characteristics of the study participants, stratified by their depressive symptoms status.
Table 1 Characteristics of study participants based on depression symptoms
Univariate analysis
Model 1
Diabetics were more likely to report depressive symptoms (OR =1.70, 95% CI: 1.26–2.90, P-value <0.0005) compared with non-diabetics. lists the crude odds ratios and 95% CIs for the different covariates of depressive symptoms.
Table 2 Crude odds ratios for depressive symptoms
Multiple logistic regression analysis
Model 2
Our results indicated that the association between diabetes and depressive symptoms remained significant after adjusting for sociodemographic variables (aOR =1.72, 95% CI: 1.22–2.42, P-value =0.0021). There was no significant effect for Aboriginal identity (P-value =0.2480), and therefore, this variable was not included in model 3.
Model 3
After adjusting for both sociodemographics and health-related behaviors, diabetes remained significantly associated with depressive symptoms (aOR =1.71, 95% CI: 1.22–2.39, P-value =0.0018). Interestingly, regular alcohol use, especially among Aboriginal participants, had a significant protective effect against depressive symptoms (aOR =0.72, 95% CI, 0.56–0.93, P-value <0.0110).
Model 4
Our results remained significant after further adjusting for clinical profile variables. The odds of having depressive symptoms for patients with diabetes were 46% higher than those reported for nondiabetics (aOR =1.46, 95% CI: 1.03–2.07, P-value =0.0168). Sociodemographic variables showed that the odds for females were 1.5 times greater than those for males (aOR =1.51, 95% CI: 1.21–1.89, P-value =0.0003), while married participants had a lower risk of reporting depressive symptoms. Health-related behaviors showed that the odds of depression among daily smokers (aOR =1.68, 95% CI: 1.33–2.11, P-value <0.0001) and drug users (aOR =1.62, 95% CI: 1.24–3.79, P-value =0.0005) were significantly greater. Focusing on the clinical profile, being diagnosed with anxiety disorders was the strongest predictor of depression (aOR =4.21, 95% CI: 3.32–5.33, P <0.0001). The results of the multivariable analysis are shown in .
Table 3 Adjusted odds ratios of depressive symptoms
Suicidal ideation
The weighted total number of Aboriginal participants who responded to the suicidal ideation questions was 6,94,960. The overall prevalence of suicidal ideation was 19.08%. The prevalence of suicidal ideation among diabetics was 23.86% compared with 18.71% among the nondiabetic respondents. depicts the characteristics of the study participants, stratified by their suicidal ideation status.
Table 4 Characteristics of study participants based on suicidal ideation status
Univariate analysis
Model 1
Diabetics were more likely to report suicidal ideation (OR =1.36, 95% CI: 1.05–1.77, P-value =0.0193) compared with nondiabetics. lists the crude odds ratios and 95% CIs for the different covariates of suicidal ideation.
Table 5 Crude odds ratios for suicidal ideation
Multiple logistic regression analysis
Model 2
After adjusting for sociodemographic variables, the association between diabetes and suicidal ideation remained significant (aOR =1.44, 95% CI: 1.09–1.92, P-value =0.0117).
Model 3
The strength of association between diabetes and suicidal ideation was maintained after adjusting for both sociodemographics and health-related behavior variables (aOR =1.40, 95% CI: 1.05–1.88, P-value =0.0231). Once again, regular alcohol users were 41% less likely (OR =0.59, 95% CI: 0.49–0.72, P-value <0.0001) to self-report suicidal ideation compared with nonusers.
Model 4
Our results found that the risk of suicidal ideation among diabetics was no longer significant after additionally controlling for the effects of health-related variables (aOR =1.17, 95% CI: 0.87–1.56, P-value =0.3012). Sociodemographic variables showed that individuals aged 35–54 years old had significantly higher risk of reporting suicidal ideation (aOR=1.23, 95% CI: 1.01–1.64, P-value =0.0385). Consistent with our depression findings, being male, married, or living in common-law relationship was associated with significant lower risk of reporting suicidal ideation. Health-related behaviors showed that drug users (aOR=2.82, 95% CI: 2.33–3.42, P-value <0.0001) and daily smokers (aOR =1.39, 95% CI: 1.17–1.64, P-value =0.0001) are at higher risk of suicidal ideation, while regular alcohol use maintained its protective effect. Clinical profile variables showed that mood disorders were the strongest predictor of suicidal ideation (aOR =4.64, 95% CI: 3.77–5.72). Participants diagnosed with anxiety disorders (aOR =1.52, 95% CI: 1.22–1.88) or chronic illnesses (aOR =1.73, 95% CI: 1.44–2.07) were more likely to report suicidal ideation. illustrates the results of the multivariable analysis with suicidal ideation as the outcome of interest.
Table 6 Adjusted odds ratios of suicidal ideation
Discussion
In the present study, we examined the association between diabetes, depression, and lifetime suicidal ideation in a national sample of the Aboriginal Canadian peoples living off-reserve. Our data show that diabetics are at significantly higher risk of experiencing depressive symptoms compared with their nondiabetic counterparts. That effect maintained its strength after adjusting for sociodemographics, health-related behaviors and clinical profile factors. Furthermore, our results indicated that diabetes was associated with higher risk of suicidal ideation, when considering sociodemographic and health-related behavioral factors.
The crude prevalence of depressive symptoms among Aboriginal diabetic participants was 17.53% compared to 11.12% among nondiabetics. Our study findings corroborate those reported by Davis et al, who examined depression among Aboriginal Type 2 diabetic patients in Australia. They found prevalence rates to be higher than those reported among the general Australian population.Citation22 However, other studies contradict our findings. One of these studies assessed depression (and other factors) among Canadian Aboriginal participants with impaired glucose tolerance and Type 2 diabetes. They found no difference in the prevalence between the diabetic and prediabetic group compared to the normoglycemic group. Yet, this study suffered from a number of limitations including a high risk of selection bias and limited study power.Citation41
The high prevalence of depression observed in our study is concerning, especially when one considers the findings reported in the literature that help highlight the lack of attention to depression screening and management among Aboriginal diabetic patients in primary health care settings.Citation34,Citation42 Therefore, it is not surprising to note the many negative consequences of untreated depression, especially in the cases of Aboriginal diabetics, which may manifest as higher burdens of disability, increased cost of hospitalization, and even premature death.Citation43
Our results show that diabetes was independently associated with higher risk of experiencing depressive symptoms among Aboriginal peoples, even after adjusting for all control variables. This finding supports the growing body of literature that suggests that diabetes and depression are related.Citation6,Citation18,Citation19,Citation44,Citation45 There is evidence of a bidirectional association whereby diabetes increases the risk of depressionCitation6,Citation18,Citation19 and depression increases the risk of diabetes.Citation44,Citation45 Given the exploratory, cross-sectional nature of our study, our results confirm the existence but are unable to determine the directionality of this association.
Among the more plausible explanations for the association between diabetes and depression among the Aboriginal Canadian population is the role played by socioeconomic status (SES). In general, SES is a strong predictor of both diabetes and depression.Citation46–Citation48 SES plays an important role as diabetes is known to be inversely related to the level of income, education, and housing.Citation49,Citation50 Within the Canadian Aboriginal context, the social, cultural, and economic inequalities experienced by this population, adversely impact their SES.Citation51 Their continued struggle to meet basic needs with limited resources, disadvantageous conditions, and risky behaviors (eg, smoking, alcohol drinking, and drug use) impose high levels of chronic stressCitation52 that may lead to the development of diabetes, depression, and suicidal behavior.Citation53,Citation54
In our study, the prevalence of lifetime suicidal ideation among Aboriginal diabetics was 23.86% compared to 18.71% in nondiabetic respondents. Controlling for the differences in socioeconomic and health-related behavioral factors, diabetes was a statistically significant predictor of suicidal ideation, which is in concordance with previous studies.Citation55,Citation56 This finding may not be surprising as depression is a strong risk factor for suicidal behavior,Citation57 and therefore, it can act as a mediating step in the association between diabetes and suicidal behavior.Citation58
Nevertheless, when considering the problems of diabetes and suicidal ideation in the Aboriginal population of Canada, historical context cannot be ignored. For example, the effect of the traumatic experiences of Aboriginal peoples in residential schools has been linked to both suicidal behavior and diabetes.Citation59,Citation60 It was demonstrated that the structural violence practiced in residential schools not only increased the risk of suicidal behavior among the schools’ attendees but also their descendants by suffering from “intergenerational trauma”.Citation59 Additionally, these institutions suppressed indigenous dietary practices and replaced traditional healthy foods with western foods that are high in salt, sugar, and fat.Citation60 These unhealthy dietary practices were maintained in later generationsCitation60 and may have contributed to the epidemic of diabetes in the Aboriginal population.
It is interesting to note that, in our results, regular alcohol use was associated with a significant protective effect for depressive symptoms and suicidal ideation. This finding seems to contradict those previously published in the literature. These studies mainly focused on heavy and hazardous use of alcohol and found a positive association with depression and suicidal behavior.Citation61–Citation63 Other studies have also described a J-shaped relationship, whereby regular low-to-moderate drinkers have experienced lower risk of depression relative to abstainers.Citation64,Citation65 Several explanations for this pattern have been proposed, which include the following: 1) a direct protective effect of alcohol on depression, similar to its effect on coronary heart diseaseCitation66 and 2) social aspects of alcohol use related to drinking behavior, whereby in certain cultures, low-to-moderate regular drinkers may psychologically benefit by becoming better socially adjusted compared with those who never drink alcohol.Citation64 However, our study findings should be interpreted with caution since key details in alcohol use were not available (eg, frequency, quantity, volume, duration) among our participants, which could significantly change the pattern of the interrelationship between alcohol use, depression, and suicidal behavior.Citation67
Strengths and limitations
This study has several strengths, which include the following: 1) a large, representative, national sample; 2) use of weights to statistically adjust our sample, which resulted in the generalizability of our findings among the Aboriginal Canadian population living off-reserve; 3) adjusting for a wide variety of factors (sociodemographic, health-related behavior, and clinical profile variables); and 4) participants were not recruited based on their diabetes, depression, or suicidal ideation status, therefore, the potential for selection bias was minimal.
This study also has some limitations: 1) the cross-sectional design is helpful in identifying the associations between diabetes, depression, and suicidal ideation, but cannot be used to infer directionality and causality; 2) the use of self-report survey data may be prone to recall bias and social desirability but the validity of the survey has been well established;Citation29 3) due to the sensitivity of the topics and possible stigmatization, there is a possibility that participants with depression or suicidal ideation either did not participate in the survey or did not accurately respond to particular questions; and 4) according to Statistic Canada, the sample used for the suicidal ideation question may not be representative for those <18 years old and therefore, caution is required in interpreting the findings.
Implications for research and clinical practice
This study provides previously unavailable information about diabetes, depression, and suicidal ideation in the Aboriginal Canadian population living off-reserve. It underscores the need to improve awareness among diabetic patients and health care providers on the common co-occurrence of these conditions. It also highlights the importance of depression and suicidal behavior screening for diabetic patients in primary health care settings. Screening and management of depression and suicidal behavior is complicated in Aboriginal patients due to cultural differences that can represent a barrier to effective screening. Therefore, when developing and implementing health policies and health promotion initiatives to address depression and suicidal behavior among Aboriginal diabetics, focus should be given on culturally sensitive and acceptable strategies.
Further research is needed to understand the potential biological and psychological mechanisms implicated in the association between depression and suicidal behavior in patients with diabetes. Longitudinal studies are required to characterize risk factors, identify the course and effect of comorbidity, and assess how it relates to prognosis and response to treatment. It is essential when conducting research with Aboriginal peoples to use an intersectional approach to study the interplay between different social, political, and cultural factors. Future research that examines the patterns of alcohol use among Aboriginal diabetic patients and its effect on development of depression and suicidal behavior is required.
Conclusion
Our study found that the Aboriginal Canadian diabetic population living off-reserve is at higher risk of experiencing depressive symptoms and suicidal ideation compared with nondiabetic Aboriginal population. Raising awareness, improving the training of health care professionals, and developing culturally appropriate co-screening strategies are important steps in reducing the burden of depression and suicidal behavior among Aboriginal diabetics. Such co-screening efforts can help in the early identification and management of these complex cases and decrease the burden of further disability, hospitalization, and premature death. Future research is required to elucidate the temporal nature of the association between diabetes, depression, and suicidal ideation among the Aboriginal peoples of Canada.
Ethical approval
This study is exempt from ethics approval because it relies on the use of Statistics Canada public files and secondary analysis of anonymous data (Tri-Council Policy Statement, articles 2.2 and 2.4, respectively). Participation in this survey was voluntary.
Acknowledgments
The authors would like to thank Ms. Jocelyn Orb and Ms. Rita Hanoski, Student Health Services, University of Saskatchewan for their kind assistance and support in this project.
Disclosure
The authors report no conflicts of interest in this work.
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