Diabetes mellitus (DM) is a chronic metabolic disorder characterized by persistent hyperglycemia resulting from defects in insulin secretion, insulin action, or both. It has become one of the most pressing public health concerns worldwide due to its high prevalence, disabling complications, and socioeconomic burden. According to the International Diabetes Federation (IDF) Diabetes Atlas, 10th edition, an estimated 537 million adults are living with diabetes globally, a figure projected to rise to 643 million by 2030 and 783 million by 2045 [1]. India is among the countries most affected, with approximately 77 million individuals currently living with diabetes, often referred to as the “diabetes capital of the world” [1].

While the physical complications of diabetes—including retinopathy, nephropathy, neuropathy, cardiovascular disease, and cerebrovascular disease—are well established, the psychological consequences are frequently overlooked. The chronic and demanding nature of DM requires lifelong lifestyle modifications, regular medical follow-up, strict dietary control, and consistent adherence to pharmacotherapy. The constant vigilance and fear of acute and long-term complications can place a substantial psychological burden on patients, predisposing them to depression, anxiety, and stress [2,3].

Depression has been found to be nearly twice as prevalent in diabetic patients compared to the general population [4]. A meta-analysis by Anderson et al. (2001) revealed that approximately one in four diabetic patients suffers from depression [4]. Anxiety is another common comorbidity, particularly related to concerns such as fear of hypoglycemia, long-term disability, and uncertainty about future health [5]. Stress, both acute and chronic, has a bidirectional relationship with DM—psychological stress activates neuroendocrine pathways, increasing counter-regulatory hormones (e.g., cortisol, catecholamines), which worsen glycemic control, while poor glycemic control and complications further heighten stress levels [6].

The interrelationship between diabetes and psychological morbidity creates a vicious cycle. Psychological distress adversely affects self-care behaviors such as dietary adherence, physical activity, glucose monitoring, and medication compliance [7]. Poor self-care contributes to worsening glycemic control, increased risk of complications, and higher healthcare costs. In turn, disease progression exacerbates mental health problems, creating a feedback loop that complicates disease management [8].

Evidence suggests that untreated depression and anxiety in diabetic patients are associated with poorer quality of life, greater functional impairment, increased risk of complications, higher healthcare utilization, and elevated mortality [9,10]. Despite this, psychological comorbidities remain underdiagnosed and undertreated in routine clinical practice, particularly in low- and middle-income countries such as India, where healthcare systems prioritize glycemic and physical complication management over psychosocial care [11].

In India, regional studies assessing depression, anxiety, and stress in diabetic patients have reported variable prevalence rates, ranging from 25–45% for depression, 30–50% for anxiety, and 20–35% for stress, depending on population characteristics and screening instruments used [12–14]. However, there is limited comprehensive research evaluating all three dimensions together in the same population.

Given the increasing burden of diabetes in India and the growing recognition of the psychosocial dimension of chronic diseases, it becomes imperative to explore the prevalence and determinants of mental health comorbidities in diabetic patients. The present study was conducted to estimate the prevalence of depression, anxiety, and stress among patients with diabetes mellitus and to evaluate their association with sociodemographic and clinical factors. The findings aim to highlight the importance of incorporating routine psychological screening and support into diabetes management programs to improve patient outcomes and overall quality of life.

MATERIALS AND METHODS:

Study design and setting

This was a hospital-based cross-sectional study conducted in the Department of Medicine in collaboration with the Department of Psychiatry of a tertiary care teaching hospital over a period of 6 months.The study aimed to assess the prevalence of depression, anxiety, and stress and identify associated sociodemographic and clinical factors among patients with diabetes mellitus.

Study population

The study population comprised adult patients (≥18 years) diagnosed with type 1 or type 2 diabetes mellitus, attending the outpatient or inpatient departments during the study period.

Inclusion criteria:

1. Adults (≥18 years) with a confirmed diagnosis of diabetes mellitus (based on ADA 2025 criteria) [15].
2. Patients who provided written informed consent.

Exclusion criteria:

1. Patients with known psychiatric disorders or currently receiving psychiatric treatment.
2. Critically ill patients or those unable to complete the questionnaire due to cognitive impairment or communication difficulties.
3. Pregnant women with gestational diabetes.

Sample size calculation

The sample size was calculated for estimating a single proportion using the formula:

n=Z²⋅p⋅(1−p)/d²

Where:

• Z=1.96 at 95% confidence interval
• p=0.20 (expected prevalence of anxiety disorder in pregnancy from previous studies)
• d=0.05 (absolute error)

n=(1.96)^2⋅x0.30x0.70/(0.05)² =323

​Accounting for a 10% non-response rate, the final target sample size was 359 (~360 patients).

Data collection tools and procedure

Sociodemographic and clinical data

A structured proforma was used to collect information on:

• Age, gender, education, occupation, marital status
• Duration of diabetes
• Glycemic control (most recent HbA1c)
• Presence of diabetic complications (neuropathy, retinopathy, nephropathy, cardiovascular disease)
• Treatment modality (oral hypoglycemic agents, insulin, or combination)

Assessment of psychological morbidity

Psychological status was assessed using the Depression, Anxiety, and Stress Scale-21 (DASS-21), a validated self-report instrument widely used in clinical and research settings. The DASS-21 consists of 21 items, divided equally into three domains: depression, anxiety, and stress. Each item is scored on a 4-point Likert scale (0–3), and domain scores are summed and multiplied by 2 to obtain the final score. Severity categories were classified as normal, mild, moderate, severe, and extremely severe according to standard cut-offs [17].

Procedure

• Eligible patients were approached in the OPD or inpatient wards.
• After explaining the study, written informed consent was obtained.
• The proforma and DASS-21 questionnaire were administered in English or local language, with assistance provided if required.
• Clinical data including HbA1c and complications were extracted from medical records.

Ethical considerations

The study was approved by the Institutional Ethics Committee All procedures were conducted in accordance with the Declaration of Helsinki. Participants’ confidentiality was maintained, and participation was voluntary. Patients identified with severe or extremely severe psychological symptoms were referred to psychiatry services.

Statistical analysis

Data were entered into Microsoft Excel  and analyzed using SPSS version 20

• Descriptive statistics: Mean ± standard deviation (SD) for continuous variables; frequency and percentages for categorical variables.
• Bivariate analysis: Associations between sociodemographic/clinical variables and psychological morbidity (any vs none) were assessed using Chi-square test.
• Multivariable logistic regression: Independent predictors of depression, anxiety, and stress were determined. Variables with p <0.2 in bivariate analysis were entered into the model. Results were reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI).
• Significance level: p <0.05 was considered statistically significant.

Top of Form

Bottom of Form

RESULTS:

A total of 360 diabetes mellitus patients were included, with a mean age of 52.4 ± 11.6 years. Males comprised 56.9% and females 43.1%. More than half (53.6%) had diabetes for ≥5 years, 58.9% had poor glycemic control, and 31.9% reported complications as shown in Table 1

Table 1. Sociodemographic and clinical characteristics

The overall prevalence of depression, anxiety, and stress was 38.0%, 46.1%, and 28.1%, respectively. Anxiety was the most frequent psychological morbidity, followed by depression and stress as shown in Table 2

Table 2. Distribution of DASS-21 severity categories

Bivariate associations : Chi-square tests were used to examine associations between key variables and presence/absence of each psychological morbidity (any vs none). p-values <0.05 considered significant.

Females, patients with longer duration of diabetes, poor glycemic control, and presence of complications showed significantly higher prevalence of depression and anxiety. Stress was particularly higher among those with longer duration and complications as shown in Table 3

Table 3. Selected associations (counts and percentages within subgroup)

* statistically significant (p < 0.05)

Multivariable logistic regression models were constructed separately for each outcome (depression, anxiety, stress). Variables entered: age (continuous), gender (female vs male), duration of diabetes (≥5 vs <5 years), HbA1c (>7% vs ≤7%), presence of complications (yes vs no), and education level (graduate+ vs lower). Results shown as adjusted odds ratios (aOR), 95% confidence intervals (CI) and p-values as shown in Table 4, Table 5 & Table 6

Table 4. Adjusted predictors of depression (n = 360)

Table 5. Adjusted predictors of anxiety (n = 360)

Model fit: Hosmer-Lemeshow p = 0.38.

Table 6. Adjusted predictors of stress (n = 360)

Interpretation (multivariable models):

• Female gender, longer diabetes duration (≥5 years), poor glycemic control (HbA1c >7%) and presence of complications independently predict higher odds of depression.
• For anxiety, poor glycemic control and presence of complications are independent predictors; female gender has borderline significance.
• For stress, longer duration and complications are independent predictors.

DISCUSSION:

The present study evaluated the prevalence of depression, anxiety, and stress among 360 patients with diabetes mellitus attending a tertiary care hospital. Our findings indicate that psychological morbidity is highly prevalent in this population, with 38.0% of patients exhibiting depression, 46.1% anxiety, and 28.1% stress. These results underscore the significant psychosocial burden of diabetes, consistent with prior literature highlighting the interplay between chronic metabolic disease and mental health [18–20].

Comparison with previous studies

The prevalence of depression in our study (38.0%) is comparable to the findings of Balhara et al., who reported a 35–40% prevalence among Indian type 2 diabetes patients [21]. It is slightly higher than the global estimate of ~25% reported in a meta-analysis by Anderson et al. [22], possibly reflecting differences in study settings, population characteristics, and screening tools.

Anxiety was the most prevalent morbidity in our study (46.1%). Similar findings were reported in Indian studies by Raval et al. and Solanki et al., who documented anxiety in 40–50% of patients [23,24]. The elevated prevalence of anxiety in diabetic populations may be attributed to fear of hypoglycemia, disease complications, and lifestyle restrictions imposed by chronic illness [25].

The prevalence of stress (28.1%) aligns with findings from regional studies, though fewer studies specifically report stress as a separate domain. Chronic stress in diabetes is often linked to the demands of self-care, fear of complications, and the psychological impact of disease progression [26,27].

Sociodemographic and clinical correlates

In this study, female gender was associated with higher prevalence of depression and anxiety, consistent with global evidence that women with diabetes are more prone to psychological distress [28,29]. Potential explanations include greater societal and family responsibilities, differences in coping mechanisms, and biological susceptibility.

Longer duration of diabetes (≥5 years) was independently associated with higher risk of depression and stress, which can be explained by the cumulative burden of disease, experience of complications, and lifestyle restrictions over time [30].

Poor glycemic control (HbA1c >7%) was significantly associated with depression and anxiety, supporting previous reports that psychological distress may interfere with adherence to medications, diet, and lifestyle measures, while hyperglycemia itself can contribute to mood disturbances via neuroendocrine mechanisms [31,32].

Presence of diabetic complications was a strong predictor of psychological morbidity. Complications such as neuropathy, retinopathy, and nephropathy not only impair quality of life but also increase anxiety about future health, reduce functional independence, and impose financial stress [33,34].

Possible mechanisms

The bidirectional relationship between diabetes and mental health has been widely recognized. Psychological distress can impair self-care behaviors, leading to poor glycemic control, which in turn exacerbates emotional burden—a vicious cycle. Biological mechanisms include dysregulation of the hypothalamic–pituitary–adrenal axis, chronic inflammation, and altered neurotransmitter function, which may contribute to depression and anxiety in diabetic patients [35,36].

CONCLUSION: Our study demonstrates that psychological morbidity is common among patients with diabetes mellitus, with anxiety being the most prevalent, followed by depression and stress. Female gender, longer duration of diabetes, poor glycemic control, and presence of complications were significant predictors. These findings highlight the importance of integrating mental health evaluation and support into routine diabetes care to improve both psychological well-being and diabetes outcomes.

REFERENCES:

1. International Diabetes Federation. IDF Diabetes Atlas. 10th ed. Brussels, Belgium: IDF; 2021.
2. Lloyd CE, Roy T, Nouwen A, Chauhan AM. Epidemiology of depression in diabetes: International and cross-cultural issues. J Affect Disord. 2012;142(Suppl):S22–9.
3. Pouwer F. Should we screen for emotional distress in type 2 diabetes mellitus? Nat Rev Endocrinol. 2009;5(12):665–71.
4. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):1069–78.
5. Smith KJ, Béland M, Clyde M, Gariépy G, Pagé V, Badawi G, et al. Association of diabetes with anxiety: A systematic review and meta-analysis. J Psychosom Res. 2013;74(2):89–99.
6. Surwit RS, Schneider MS, Feinglos MN. Stress and diabetes mellitus. Diabetes Care. 1992;15(10):1413–22.
7. Fisher L, Skaff MM, Mullan JT, Arean P, Mohr D, Masharani U, et al. Clinical depression versus distress among patients with type 2 diabetes: Not just a question of semantics. Diabet Med. 2007;24(3):382–5.
8. Lustman PJ, Anderson RJ, Freedland KE, de Groot M, Carney RM, Clouse RE. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care. 2000;23(7):934–42.
9. Gonzalez JS, Peyrot M, McCarl LA, Collins EM, Serpa L, Mimiaga MJ, Safren SA. Depression and diabetes treatment nonadherence: a meta-analysis. Diabetes Care. 2008;31(12):2398–403.
10. Katon WJ, Lin EH, Kroenke K. The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. Gen Hosp Psychiatry. 2007;29(2):147–55.
11. Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management of diabetes mellitus. J Diabetes Metab Disord. 2013;12(1):14.
12. Balhara YP, Sagar R. Correlates of anxiety and depression among patients with type 2 diabetes mellitus. Indian J Endocrinol Metab. 2011;15(Suppl1):S50–4.
13. Raval A, Dhanaraj E, Bhansali A, Grover S, Tiwari P. Prevalence & determinants of depression in type 2 diabetes patients in a tertiary care centre. Indian J Med Res. 2010;132(2):195–200.
14. Solanki JD, Makwana AH, Mehta HB, Gokhale PA, Shah CJ. Anxiety and depression in type 2 diabetes mellitus. J Res Med Dent Sci. 2014;2(3):25–9.
15. American Diabetes Association. Standards of Medical Care in Diabetes—2025. Diabetes Care. 2025;48(Suppl 1):S1–S120.
16. Balhara YP, Sagar R. Correlates of anxiety and depression among patients with type 2 diabetes mellitus. Indian J Endocrinol Metab. 2011;15(Suppl1):S50–4.
17. Lovibond SH, Lovibond PF. Manual for the Depression Anxiety & Stress Scales, 2nd ed. Sydney: Psychology Foundation; 1995.
18. Pouwer F. Should we screen for emotional distress in type 2 diabetes mellitus? Nat Rev Endocrinol. 2009;5(12):665–71.
19. Lloyd CE, Roy T, Nouwen A, Chauhan AM. Epidemiology of depression in diabetes: International and cross-cultural issues. J Affect Disord. 2012;142(Suppl):S22–9.
20. Fisher L, Skaff MM, Mullan JT, et al. Clinical depression versus distress among patients with type 2 diabetes: Not just a question of semantics. Diabet Med. 2007;24(3):382–5.
21. Balhara YP, Sagar R. Correlates of anxiety and depression among patients with type 2 diabetes mellitus. Indian J Endocrinol Metab. 2011;15(Suppl1):S50–4.
22. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):1069–78.
23. Raval A, Dhanaraj E, Bhansali A, et al. Prevalence & determinants of depression in type 2 diabetes patients in a tertiary care centre. Indian J Med Res. 2010;132(2):195–200.
24. Solanki JD, Makwana AH, Mehta HB, et al. Anxiety and depression in type 2 diabetes mellitus. J Res Med Dent Sci. 2014;2(3):25–9.
25. Smith KJ, Béland M, Clyde M, et al. Association of diabetes with anxiety: A systematic review and meta-analysis. J Psychosom Res. 2013;74(2):89–99.
26. Surwit RS, Schneider MS, Feinglos MN. Stress and diabetes mellitus. Diabetes Care. 1992;15(10):1413–22.
27. Templin T, Tatum T, Donohue RM. Stress, coping, and diabetes. Diabetes Educ. 2010;36(6):973–80.
28. Katon WJ, Lin EH, Kroenke K. The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. Gen Hosp Psychiatry. 2007;29(2):147–55.
29. Gonzalez JS, Peyrot M, McCarl LA, et al. Depression and diabetes treatment nonadherence: a meta-analysis. Diabetes Care. 2008;31(12):2398–403.
30. Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management of diabetes mellitus. J Diabetes Metab Disord. 2013;12(1):14.
31. Lustman PJ, Anderson RJ, Freedland KE, et al. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care. 2000;23(7):934–42.
32. Lloyd CE, Dyer PH, Barnett AH. Prevalence of symptoms of depression and anxiety in a diabetes clinic population. Diabet Med. 2000;17(3):198–202.
33. Lin EH, Katon W, Von Korff M, et al. Relationship of depression and diabetes self-care, medication adherence, and preventive care. Diabetes Care. 2004;27(9):2154–60.
34. Mezuk B, Eaton WW, Albrecht S, Golden SH. Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care. 2008;31(12):2383–90.
35. Surwit RS, Feinglos MN. Stress and diabetes mellitus. Diabetes Care. 1992;15:1413–22.
36. Black PH. The inflammatory response is an integral part of the stress response: Implications for atherosclerosis, insulin resistance, type II diabetes, and metabolic syndrome X. Brain Behav Immun. 2003;17(5):350–64.