It is well documented that development of co-morbid anxiety and/or depression in people with diabetes not only leads to increased disease severity, complications, work disability, poor quality of life but is also associated with increased use of medical services and substantially higher health care costs [3, 4, 24, 25].
A higher prevalence of anxiety and depression has been reported among people with chronic diseases [26, 27] including diabetes [7, 8]. It is also reported in general as well as in patient populations, that depression and other psychological problems are more prevalent in developing countries [28–30]. There are some possible explanations are reported about the high levels of anxiety and depression in developing countries compared to developed countries like higher level of gender inequities, social insecurity, lower level of education, greater level of poverty, financial difficulties and other forms of economic stressors [29, 30]. In our study as well, high proportions of patients with type 2 diabetes were found positive for anxiety and depression, 58% and 44% respectively. These estimates are almost twice as high as found among people with diabetes in developed countries [7, 15, 16].
It is well known that being female is significantly associated with depression in general populations [29, 30] and also among people with diabetes [15, 16] and this study also showed a similar association. A possible explanation is that women play many gender specific roles, which exposes them to increased work demands and responsibilities. Furthermore, the social role attributed to women (passivity, dependence and emotional expression), allows them to be more emotional and extroversive in nature, in comparison to men [2, 30]. Hence being female is an independent factor associated with depression.
Researchers [24, 31] reported a significant association of age with depression and other psychological disorders. This study also showed increased age as an independent factor for depression. It is well reported that older patients face many challenges including isolation, more diseases and disabilities; hence making them more prone to developing psychological conditions . Similarly, duration of diabetes is also associated with development of depression in this study and has been reported by other researchers as well [31, 33]. Increased duration of the disease is known to significantly increase the risk of developing diabetic complications and health care expenditures , as a result such patients are more prone to develop psychological illnesses.
Due to an increased release of β-endorphins and brain neurotransmitters during exercise, physical activity is known to have protective physiological effects on depression and serves as a buffer against development of psychological illness [34, 35]. Khuwaja et al  and Hong et al  identified that physical activity was inversely associated with the presence of anxiety depression among various groups of population. In our study also physical inactivity was found to be independently associated with anxiety.
Cardiovascular diseases have been identified as an independent factor for anxiety and depression in various studies among people with diabetes [4, 17, 27]. Similarly, a positive contribution of type 2 diabetes to increased rates of depression and/or anxiety disorders in patients with hypertension has been suggested . In this study, having IHD and hypertension were also found to be independently associated with both anxiety and depression. These results reflect the fact that the likelihood of anxiety and depression increases with development of complications among people with diabetes.
There are inconsistent and conflicting findings regarding the relationship of MetS with anxiety and depression . Some studies observe that MetS is associated with depression [18, 19] while others have found no association with either entity . Underlying issues in all such studies are that syndrome definitions were not standardized, and their use could either mask or reflect associations with their specific components. However, a core component of all such definitions is obesity and, among people with diabetes, obesity has been consistently identified as an independent factor associated with depression [18, 20, 39]. In our study also, BMI was found to be independently associated with depression, while associations of other MetS components (elevated systolic BP, fasting BG, fasting TG) were observed with both anxiety and depression. Our results therefore support the association of obesity and other MetS components with these conditions.
This study has some limitations to be noted. Being a cross-sectional study, we could not assess the temporal relationships between anxiety, depression and other diabetes related variables. Causality therefore cannot be attributed. Some missing values of fasting BG and fasting BT were imputed. Values of High Density Lipoproteins (another component of MetS) were largely missing; hence not analyzed. All the study participants were only from clinics of urban setting, so caution must be exercised in generalizing these results.