according to the world health organization ( who ) , diabetes is likely to be one of the most substantial threats to human health in the 21 century ; 346 million people worldwide have diabetes .
type 2 diabetes typically develops in older people . among people aged 65 years and older ,
type 2 diabetes is diagnosed 10 times more frequently than in people younger than age 45 years .
however , it has been noticed that the average age of patients with type 2 diabetes mellitus is decreasing .
depression is associated with a variety of diabetes complications ( diabetic retinopathy , nephropathy , neuropathy , and macrovascular complications ) .
after the diagnosis of diabetes mellitus , people must change their everyday lifestyle and adapt to the new conditions of life ; also , they experience many negative emotions that cause lower social adaptation , and they experience decreased efficiency and disability .
the prevalence of the symptoms of anxiety ( 32% ) and depression ( 22.4% ) in patients with diabetes is considerably higher than in general population samples ( 10% ) .
diabetes doubles the likelihood of comorbid depression , which is present in approximately 30% of patients with type 1 or type 2 diabetes . a study by khuwaja et al
. found that the prevalence of depression and anxiety among adults with type 2 diabetes was 44% and 58% , respectively . both depression and anxiety
different studies have been performed and are currently being carried out in a number of countries all over the world to analyze the influence of various factors , including disease , its duration , social factors , complications , and treatment methods , on the emotional state of diabetic patients .
evidence from several studies suggests that detection and effective treatment of depression can improve diabetic control .
the presence of symptoms of depression significantly impairs the health - related quality of life among individuals with type 2 diabetes . anxiety and
depression symptoms often remain unrecognized and , thus , untreated . screening for and treatment of anxiety and depression may lead to a better medical prognosis and better quality of life .
it is important to estimate the prevalence of anxiety and depression symptoms and factors associated with these symptoms in patients with diabetes .
there is limited or controversial information regarding factors associated with anxiety and depression in patients with type 2 diabetes .
the aim of this study was to evaluate prevalence and determinants of anxiety and depression symptoms in patients with type 2 diabetes ( t2 dm ) .
patients were selected for the survey by applying the following inclusion criteria : men and women , 35 years of age or older , with type 2 diabetes mellitus , and without any acute diseases diagnosed during the survey . the hospital anxiety and depression scale ( hads )  
was used to measure depression and anxiety for the evaluation of depressive state and anxiety .
it is well - validated instrument and has been used in other chronic disease patient populations .
hads consists of 14 statements : 7 questions of the questionnaire are designed for anxiety symptoms , and the other 7 statements evaluate depression symptoms .
four possible answers ( 03 ) are given for the each statement , and the subjects must choose the one that most precisely reflects their condition last week .
the results for the depression and anxiety are summed and evaluated separately : a score of 07 means there is no depression or anxiety and a score of 8 or over means there is depression or anxiety .
a brief patient health questionnaire was used to collect demographic data , duration of the disease ( in years ) , complications , and arterial hypertension .
the study was approved by lithuanian bioethics committee and the survey was conducted in compliance with the requirements of the professional ethics of sociological - medical research . in total , 1500 patients were invited to participate in study . before presenting the survey form ,
after agreeing to participate in the survey , the subjects filled out the provided forms independently . according to the duration of the disease , the patients were distributed into 4 groups : patients who had diabetes for up to 5 years , patients who had diabetes for 610 years , those who had the disease for 1115 years , and those who had diabetes for 16 years or more .
we evaluated the distribution of the respondents according to the following complications of diabetes : nephropathy , retinopathy , angiopathy , and polyneuropathy of legs .
also , they were asked if they were diagnosed with arterial hypertension , and whether they used medicines for the treatment of hypertension .
the prevalence of anxiety and depression symptoms were assessed using hads cut - off points : 07 indicating there is no depression or anxiety and 8 and over indicating there is depression or anxiety .
pearson s  test was used for categorical data analysis and the extended mantel - haenszel test was used for trend .
the anxiety and depression scores were dichotomized prior to regression analysis : 07 was defined as a normal score , 821 was defined as a mild to severe anxiety or depression score . the odds ratios ( or ) for anxiety and depression
socio - demographic variables were specified in block 1 and health status and behavior variables were specified in block 2 .
the most patients were in age groups of 5564 years ( 38.1% ) and 6574 years ( 32.2% ) ( mean age  59.3 years ( median  59.0 ) .
more than 70% of all respondents who participated in the study had diabetes mellitus complications ( 72.2% ) .
retinopathy ( 57.5% ) and angiopathy ( 54.6% ) were the most common complications of t2 dm .
arterial hypertension ( ah ) was self - reported by 74.4% of patients with t2 dm .
the majority of patients ( 71.5% ) had no depression symptoms ( normal score 7 ) .
the prevalence mild to severe depression score was 28.5% ( 95% ci 25.731.4 ) ( table 2 ) .
depression symptoms were more prevalent in females ( 32.3% ) than in males ( 21.8% ) ( p<0.001 ) .
anxiety was more frequent among females ( 46.8% ) than among males ( 34.7% ) ( p<0.001 ) .
a significant negative trend was observed between prevalence of anxiety and depression , and age and education ( p for trend < 0.001 ) .
the prevalence of anxiety and depression symptoms among unmarried people was 55.6% ( 95%ci 35.374.5 ) , while among married people it was 36.9% ( 95%ci 33.240.7 ) and 25% ( 95% ci21.828.5 ) , respectively .
anxiety and depression were more prevalent among retired ( 49.5% [ 95% ci 44.854.3 ] and 33.3% [ 95% ci 28.937.9 ] , respectively ) and disabled persons ( 41.1% [ 95% ci31.751.1 ] and 40.2% [ 95% ci 30.850.1 ] , respectively ) compared with blue - collar and white - collar workers .
therefore , the prevalence of anxiety and depression symptoms were dependent from gender , age , marital status , education , and social status .
the prevalence of depression symptoms was higher ( p=0.007 ) among obese ( 31.0% , 95% ci 27.1834.97 ) than among overweight respondents ( 23.3% [ 95%ci 19.4527.59 ] ) .
however , the prevalence of anxiety in these groups of patients was similar ( 40.3% and 43.0% , p=0.384 ) .
prevalence of anxiety and depression symptoms was associated with duration of diabetes , diabetes complications , and self - reported arterial hypertension .
the prevalence of anxiety and depression symptoms increases with increasing duration of the disease ( p<0.001 ) .
our study results confirmed that chronic complications of diabetes mellitus affected the emotional state of patients .
the prevalence of anxiety and depression symptoms was higher among patients with complications ( 45.7% [ 95% ci 42.0349.34 ] and 33.5% [ 95% ci 30.137.0 ] ) and self - reported arterial hypertension ( 45.7% [ 95% ci 42.149.3 ] and 31.7% [ 95% ci 28.435.2 ] ) . anxiety and depression symptoms were more prevalent among insulin users ( 47.9% [ 95% ci43.252.6 ] and 39.1% [ 95% ci 34.643.8 ] , respectively ) .
the prevalence of anxiety and depression symptoms was lower among respondents who had changed their diet ( 37.2% [ 95% ci 34.140.4 ] and 24.7% [ 95% ci 21.927.6 ] , respectively ) .
increased physical activity after t2 dm diagnosis was statistically significantly ( p=0.004 ) associated with lower prevalence of anxiety symptoms ( 36.1% [ 95% ci 31.141.3 ] ) .
we found no statistically significant association between smoking and prevalence of anxiety and depression symptoms by bivariate analysis ( table 3 ) .
results of the multivariable analysis for factors associated with anxiety and depression symptoms are given in table 4 and table 5 .
age ( older age ) , education ( incomplete secondary , secondary vs. elementary ) , social status ( white - collar workers vs. blue - collar workers ) , duration of diabetes , and complications were risk factors significantly associated with higher anxiety scores .
self - reported arterial hypertension , increased physical activity after t2 dm diagnosis , and smoking were not significantly associated with anxiety .
protective factors significantly associated with lower depression scores were : marital status , education , retiree ( vs. blue - collar workers ) , and changed nutrition habits after t2 dm diagnosis .
age ( older age ) and duration of diabetes were associated with higher depression symptoms .
gender , complications , insulin using , self - reported arterial hypertension , increased physical activity after dm diagnosis , and smoking were not significantly associated with higher depression scores .
diabetes  particularly its complications  not only causes impairment of the physical health , but at the same time promotes occurrence of psycho - emotional and social problems . after the diagnosis of diabetes mellitus , people must change their everyday lifestyle and adapt to the new conditions the life .
they experience many negative emotions that cause lower social adaptation , and they face disability and decreased efficiency . co - morbid major depression is a significant problem among patients with t2 dm and/or coronary heart disease and this negatively impacts quality of life .
most epidemiological studies indicate that diabetes is associated with an increased risk of depression . in our study ,
depression was detected in 28.5% of the subjects : 32.3% for females , and 21.8% of males .
anxiety was found in 42.4% of the subjects . anxiety  like depression  was more common ( p<0.001 ) in females ( 46.8% ) than in males ( 34.7% ) .
tellez - zenteno and cardiel reported a 39% prevalence of depression , and the risk for depression in females was more than twice as high ( or 2.95 , ci 1.505.82 , p=0.006 ) as in males .
our study shows that insulin use did not affect the states of depression and anxiety , but it could lead to a longer duration of the disease and increase complications .
in addition , insulin - treated patients had more advanced disease and poor patient performance status . according to the literature , complications of t2
dm negatively affect patient health , and health impairment due to t2 dm complications increases the risk of depression .
depressive states were significantly related to the complications of diabetes , the presence of other chronic diseases , anxiety , and poorer quality of life . in our study
anxiety was more frequent among females ( 46.8% ) than among males ( 34.7% ) ( p<0.001 ) .
previous studies showed that different chronic complications influence the depressive state : neuropathy , cardiovascular diseases , retinopathy , and nephropathy   have a direct impact on the depressive state of diabetic patients .
studies showed that depression and anxiety rate depended on the duration of the disease . according to a study performed in norway ( the had scale was used ) , the probability that patients with type 2 diabetes would develop depression was the same as in the general population . the diabetes itself as a disease does not have any impact on the depressive state ( oro  1.08 ; 95% , ci 0.701.65 ; p=0.740 )  the strongest influence is exerted by complications and concomitant chronic diseases ( oro  1.38 ; 95% , ci 1.101.74 ; p<0.005 ) .
our study shows a significant negative trend between prevalence of anxiety and depression , and age and education ( p for trend < 0.001 ) .
a significant association between depression and diabetic complications has been identified . according to a meta - analysis by de groot et al . , the effect sizes for each complication were : 0.17 for retinopathy , 0.20 for macrovascular complications , 0.25 for nephropathy , 0.28 for neuropathy , and 0.32 for sexual dysfunction .
the overall effect size was small to moderate ( r=0.25 ) , and was comparable between the 2 types of diabetes .
the data of our study confirmed that chronic complications of diabetes mellitus affected the emotional state of patients .
the prevalence of anxiety and depression symptoms was higher among patients with complications ( 45.7% [ 95% ci42.0349.34 ] and 33.5% [ 95% ci 30.137.0 ] ) and self - reported arterial hypertension ( 45.7% [ 95% ci 42.149.3 ] and 31.7% [ 95% ci 28.435.2 ] ) .
a canadian study found that smoking and depression are strongly associated in patients with type 2 diabetes , and this association appears to be strongest for moderate / heavy smokers .
however , we did not find a statistically significant association between smoking and prevalence of anxiety and depression symptoms by bivariate analysis .
duration of the disease was relevant to lower rating of all fields of quality of the life except for evaluation of role limitations due to emotional problems , emotional state , and mental health . in our study
the results of the multivariable analysis for factors associated with anxiety and depression symptoms shows that diabetes duration was a risk factor significantly associated with higher scores of anxiety among patients with t2 dm .
our results confirmed the study results of malaysian research findings that individuals with diabetes of less than 2-year duration were 1.6 times more likely to have depressive symptoms than individuals with diabetes of longer duration .
females and asian indians were 1.4 times more likely to have depressive symptoms compared to males and malay diabetic individuals .
the prevalence of depression and anxiety among type 2 diabetes mellitus patients was statistically significantly higher in females than in males ( p<0.001 ) . a significant association between depression and diabetic complications was identified ( p<0.05 ) .
diabetes duration was a risk factor significantly associated with higher scores of anxiety among the patients with t2 dm .
 backgrounddepression is associated with a variety of diabetes complications , including diabetic retinopathy , nephropathy , neuropathy , and macrovascular complications . 
 the prevalence of the symptoms of anxiety ( 32% ) and depression ( 22.4% ) in patients with diabetes is considerably higher than in general population samples ( 10% ) . 
 the aim of this study was to evaluate the prevalence and determinants of anxiety and depression symptoms in patients with type 2 diabetes ( t2dm).material / methodsthis survey was conducted during 20072010 . in total , 1500 patients were invited to participate in the study . the hospital anxiety and depression scale ( hads ) 
 was used to measure depression and anxiety for the evaluation of the depressive state and anxiety . 
 statistical analysis was carried out using spss 17.0.resultsmore than 70% of all respondents who participated in the study had diabetes mellitus complications ( 72.2% ) . 
 the prevalence of mild to severe depression score was 28.5% ( 95% ci 25.731.4 ) . 
 the prevalence of anxiety was 42.4% ( 95% ci 39.345.5 ) . 
 anxiety was more frequent among females ( 46.8% ) than among males ( 34.7% ) ( p<0.001 ) . 
 a significant negative trend was observed between prevalence of anxiety and depression , and age and education ( p for trend < 0.001).conclusionsa significant association between depression and diabetic complications was identified ( p<0.05 ) . 
 duration of diabetes was a risk factor significantly associated with higher scores of anxiety among the patients with t2 dm . 
Background
Material and Methods
Results
Discussion
Conclusions