Psychological burden in Indian adults with type 2 diabetes: prevalence, overlap and predictors of diabetes distress, depression and anxiety - a cross-sectional study.

BACKGROUND: Despite growing recognition of the mental health consequences of type 2 diabetes (T2D), the prevalence, overlap and associated factors of psychological burden-encompassing diabetes distress (DD), depression and anxiety remain underexplored in the Indian population. This study aimed to examine these dimensions among Indian adults with T2D. RESEARCH DESIGN AND METHODS: This cross-sectional study included 1925 adults (≥18 years) with T2D enrolled in an online diabetes management programme at the Freedom from Diabetes Clinic, Pune, India (December 2023 to December 2024). Socio-demographic, anthropometric, clinical and biochemical data were recorded. DD, depression and anxiety were measured using the Type 2 Diabetes Distress Assessment System, Patient Health Questionnaire-9 and Generalised Anxiety Disorder-7, respectively. Multivariable logistic regression identified factors independently associated with each outcome; results were interpreted using effect size (Cohen's d) to prioritise clinical significance. RESULTS: DD was the most prevalent condition (53.1%), followed by depression (20.3%) and anxiety (17.3%). Substantial comorbidity was observed: 7.5% experienced all three conditions simultaneously, while 42.3% remained symptom-free. Depression and anxiety showed a strong intercorrelation (ρ=0.692), with moderate correlations between DD and both conditions (ρ=0.460-0.466). Absence of prior depression history was the strongest factor associated with psychological burden across all outcomes (adjusted OR (AOR)/Firth OR: DD=50.44, depression=2.11, anxiety=2.24; all p<0.001), though the large AOR for DD reflects quasi-complete separation; Firth's penalised regression yielded a consistent estimate (OR=42.67, p<0.001). The anxiety model required Firth's penalised regression as the primary method due to non-convergence in standard logistic regression caused by quasi-complete separation. Both DD and anxiety findings are presented as hypothesis-generating. Depression and anxiety were strongly co-associated (AORs >13.0). Additional factors associated with burden included younger age (<45 years), female sex, poor glycaemic control and insulin use. CONCLUSION: Indian adults with T2D experience substantial, overlapping psychological burden. These findings support the integration of routine, comprehensive mental health screening using validated tools into diabetes care, with particular attention to individuals without prior mental health history.