Transcultural Prevalence of Depression in Type 2 Diabetic Patients in Egypt and Yemen

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1 Med. J. Cairo Univ., Vol. 85, No. 3, June: , Transcultural Prevalence of Depression in Type 2 Diabetic Patients in Egypt and Yemen MOHAMED R. HALAWA, M.D.*; ABDULLAH S. BIN-NABHAN, M.D.**; ABEER A. ELEWA, M.D.*; MANAL M. ABOSHADY, M.D.* and GHADA EL-KHOULY, M.D.*** The Department of Internal Medicine and Endocrinology, Faculty of Medicine, Ain Shams University* & Hadhramout University, Yemen** and the Department of Neuropsychaitry, Faculty of Medicine, Ain Shams University***, Egypt Abstract Background: Diabetes mellitus is a common chronic metabolic disorder with chronic hyperglycemia that associated with long term damage, dysfunction and failure of various organs. Depression is a common co-morbidity among diabetics that reduces quality of life and is associated with morbidity, mortality, and health care costs. The aim of this study was to investigate the prevalence of depression among patients with type 2 diabetes in two Arabic nation, Egypt and Yemen and to examine its relationship with their socio-demographic data and clinical parameters which related to diabetes and its complications. Methods: We conducted a cross-sectional analysis of two groups; one hundred Egyptian and one hundred Yemeni patients with type 2 diabetes. Depressive symptoms were defined using Hospital, Anxiety and Depression Scale Questionnaire (HADS). Metabolic and anthropometric indicators were measured according to standard methods. Results: Within the Egyptian participants, 39% had depression compared to 34% of Yemeni participants with no significant differences between the two groups. In Egyptian diabeticsa Statistical Significant association between depression and female gender, Higher number of children, Low and very low socioeconomic levels, high mean number of cigarette smoking, lower mean number of years of education with poor glycemic control and longer duration of diabetes and the presence of complication. In Yemeni diabetics, depression was significantly associated with female gender. Birth order, Low and very low socioeconomic levels, lower mean number of years of education, poor glycemic control, Diuretic usage for medical co morbidities. Predictors of depression in type 2 diabetes specified in Egyptian as duration before diagnosis of diabetes (Odds ratio 1.291), number of cigarette per day (Odds ratio 1.23), being of low social class (Odds ratio 1.7), being a female (Odds ratio 1.5), and divorce (Odds ratio 1.2). But in Yemeni, birth order, using beta blockers, being a female (Odds ratio 1.9), and divorce (Odds ratio 1.6) were the risk factors for depression. Correspondence to: Dr. Mohamed R. Halawa, The Department of Internal Medicine and Endocrinology, Faculty of Medicine, Ain Shams University, Egypt Conclusion: There is a high prevalence of depression among Egyptian and Yemeni type 2 diabetes patients with no statistical difference. The most common significant association of diabetes and depression are poor glycemic control, female gender and low socioeconomic status despite other different cultural impacts and behavior. Key Words: Diabetes mellitus Depression Urban Rural. Introduction DIABETES mellitus is a syndrome consisting of metabolic, vascular, and neuropathic components that are interrelated. Diabetes is an increasingly important condition globally and robust estimates of its prevalence are required for allocating resources. Most people with diabetes live in low- and middle-income countries, and these countries will also see the greatest increase over the next 19 years [1]. According to IDF in 2015, there were over 7.8 million cases of diabetes in Egypt and there were 491,800 cases of diabetes in Yemen. Depression refers to a wide range of mental health problems characterized by the absence of a positive affect, low mood and a range of associated emotional, cognitive, physical and behavioral symptoms [2]. The presence of undiagnosed depression amongst people with DM is cause for concern as it prevents initiation of treatment for these concomitant conditions contributing to poor clinical outcomes [3]. Diabetes have a greater risk of depression, identification of depression may be further impeded in patients with chronic disease, such as diabetes, because the patient and/or physician may assume that low mood is a natural and inevitable result of having to cope with chronic illness [4]. If patient feel sad, blue, or down in the dumps, we have to check for: Loss of pleasure, Change in sleep pat- 869

2 870 Transcultural Prevalence of Depression in Type 2 Diabetic Patients terns, Early to rise, Change in appetite, Trouble concentrating, Loss of energy, Nervousness, Guilt, Morning sadness and Suicidal thoughts, three or more of these symptoms, or even one or two but for two weeks or more, it's time to think in depression [5]. Depression can be measured by the use of a structured psychiatric diagnostic interview and according to criteria of the diagnostic and statistical manual of psychiatric disorders (DSM-IV). However, these interviews are time consuming, therefore depression questionnaires were developed and used as screening instrument for the prevalence of depressive symptoms [6]. In our study we use the hospital, anxiety and depression scale questionnaire (HADS) which was developed by Zigmond and Snaith in the 1983 to provide clinician and scientists with a reliable, valid, and practical tool for identifying and quantifying the two most common forms of psychological disturbance in medical patients [7]. Numerous studies have confirmed the reliability and validity of the HADS within medically ill populations [8]. The aim of the work: To investigate the prevalence of depression among patients with type 2 diabetes in two Arabic nation, Egypt and Yemen and to examine its relationship with their sociodemographic data and clinical parameters which related to diabetes and its complications. Subjects and Methods This is a cross sectional study, conducted from August to November 2013 on 200 diabetic subject, 100 Egyptian were recruited from endocrine clinic of Ain Shams University Hospital in Cairo and 100 Yemeni were recruited from endocrine clinic of Ibn Sina general teaching hospital in Yemen, aged above 30 years, males and females who were diagnosed primarily as type 2 diabetes and written consent taken from them as an agreement to participate. Patients unable to communicate adequately, pregnant women and patients with severe diabetic complication that reduce functionality were excluded. All patients were subjected to: 1- Detailed diabetes history (duration, medication, evidence of any of diabetic complications, presence of co-morbidities) then all patients files were reviewed to confirm the information. 2- Demographic questionnaire was created; include the demographic information (age, sex, religion, level of education, marital status, and occupation) and socioeconomic level of the participants was determined according to the Fahmy and El-Sherbini Egyptian classification [9] into: High social class: Score 25-30, Middle social class: score 20-24, Low social class: Score Very low social class: Score < 14. This classification based on patient father and mother education, work, family income, crowding index and state of sanitation. 3- Thorough clinical examination with proper anthropometric measurement of body weight and height with calculation of BMI, which used for the sample evaluation in regard to obesity [10]. 4- Glycemic control was assessed by measuring HbA1C level, Value >7% considered uncontrolled [11]. 5- Translation of the applied hospital anxiety depression scale (HADS), It contains 14 items and two subscales one for anxiety with 7 items and one for depression with 7 items, each item is rated on a four-point scale on a Likert scale and results range from 0-3, maximum sum was 21 for each scale [12], it uses >8 as cut off score as indicator of symptoms of anxiety or depression [13]. Statistical analysis: Descriptive statistical analysis to evaluate the results for each group. The mean, standard deviation and the range of measurements for continuous data types (like age), for categorical data (like sex), the frequency and percentage were calculated. This was followed by graphic representation whenever needed to assess the distribution of the data and determine the appropriate statistical test for inferential statistical analysis, as the results were analyzed using SPSS (statistical program for social science version 12). The following statistical procedures have been used in this work. Independent sample t-test (Student s t-test), Chi-square test, Pearson s correlation coefficient was calculated to determine the strength of correlation. p-value was then computed to see if this correlation was statistically significant, analysis of clinical significance: Throughout the results, p-value was used to indicate the level of significance (p >_0.05: non-significant, p<0.05: significant and p<0.001: highly significant). Results Comparison between the Egyptian and Yemeni patients done, tabulated and results presented in Tables (1,2,3).

3 Mohamed R. Halawa, et al. 871 Table (1): Socio-demographic data of both groups compared, it shows significant difference as regard social class, religion and current residence with insignificant differences as regard age, sex, marital status, occupation, birth order, smoking status and years of education. Table (2): BMI & diabetes related variables of both groups, it reveals statistically insignificant differences as regard BMI, diabetes duration, control, complication, treatment modalities and the presence of diabetic co morbidities and its treatment modalities. Table (1): Comparing scociodemographic data of both groups. Variable Egyptian Yemenis Test p-value Age (year) Sex (No%): Male Female Religion: Muslim Christian Marital status (No%): Married Single Divorced Widow Children: Occupation (No%): Jobless Unskilled Semiskilled Skilled Semiprofessional Professional Social class (No%): High Middle Low Very low Birth order (No%): First Last Middle Others Residence: Urban Rural No. of cigarette/day Years of education 58.3± (49) 51 (51) 81 (81) 19 (19) 65 (65) 4 (4) 17 (17) 14 (14) 5± (41) 14 (14) 8 (8) 9 (9) 3 (3) 25 (25) 19 (19) 17 (17) 24 (24) 40 (40) 19 (19) 5 (5) 18 (18) 58 (58) 21 (21) 79 (79) 11.5±4 7.1±2 57±9 51 (51) 49 (49) 100 (100) 00 (00) 70 (70) 7 (7) 14 (14) 9 (9) 6± (51) 12 (12) 5 (5) 3 (3) 1 (1) 28 (28) 3 (3) 16 (16) 29 (29) 52 (52) 24 (24) 7 (7) 18 (18) 51 (51) 59 (59) 41 (41) 6±3 6±4 t-test (0.803) (0.000) (20.99) (2.3 81) t-test (0.151) (7.346) (13.704) (1.364) Fisher (33.628) t-test (1.75) t-test (2.08) Table (2): BMI and diabetes related variables of both groups. Variable Egyptian Yemenis Test p-value Duration of DM in years BMI (kg/m 2 ) A 1 c (%) Treatment: Oral Insulin Both Complications no%: Yes No Co morbidities: No (%) Hypertension Dyslipidemia Both Others Drug for comorbidities: Single drug More than one drug 6.2±3 27.5±4 8.6± (55) 25 (25) 20 (20) 51 (51) 49 (49) 45 (45) 32 (32) 2 (2) 16 (16) 5 (5) 14 (25.5%) 41 (74.5%) 4.9±2 25.2±6 8.4± (63) 22 (22) 15 (15) 54 (54) 46 (46) 49 (49) 37 (37) 3 (3) 9 (9) 2 (2) 19 (3 8.0%) 32 (62.0%) t-test (3.15) t-test (1.25) 20 (20) (0.321) (20)

4 872 Transcultural Prevalence of Depression in Type 2 Diabetic Patients Table (3): Proportion of depression in Egyptians (39%) and Yemenis (34%) with no significant differences between them. Comparison between the depressed and nondepressed participant of both groups Tables (4,5). Table (4): Socio demographic data of the nondepressed and depressed patients of both groups. In Egyptian diabetic we found significant differences as regard sex, number of children, social status, Number of cigarette per day and years of education. However, in Yemeni diabetics we found significant differences as regard sex, marital status, number of children, social status and years of education. Table (5): BMI and diabetes related variables between depressed and non-depressed diabetics in both groups as, in Egyptians there is significant difference as regard duration of diabetes, control of diabetes and presence of complications. In Yemeni participants it showed significant differences as regard control of diabetes being poorer in depressed group. Table (3): Proportion of depression in Egyptians and Yemenis. Participating groups Normal No% Depressed No% p-value Egyptians Yemenis Table (4): Compare the non-depressed and depressed patients of both groups regarding socio demographic data. Variable no% Non depressed (61%) Egyptian Depressed (39%) p Non depressed (66%) Yemenis Depressed (34%) p Age 57.26± ± ± ± Sex No (%): Male 34 (55.7) 15 (38.5) (63.3) 9 (26.5) Female 27 (44.3) 24 (61.5) 24 (36.7) 25 (73.5) Religion: Muslim 51 (83.6) 30 (76.9) (1 00) 34 (100) NA Christian 10 (16.4) 9 (23.1) 00 (00) 00 (00) Marital state: Married 45 (73.8) 20 (51.3) (81.8) 16 (47.1) Single 2 (3.3) 20 (5.1) 3 (4.5) 4 (11.8) Divorced 9 (14.8) 8 (20.5) 7 (10.6) 7 (20.6) widow 5 (8.2) 9 (23.1) 2 (3.0 7 (20.6) Occupation: Jobless 24 (39.3) 17 (43.6) (50) 18 (52.9) 0.76 Unskilled 8 (13.1) 6 (15.4) 8 (12.1) 4 (11.8) Semiskilled 5 (8.2) 3 (7.7) 4 (6.1) 1 (2.9) Skilled 5 (8.2) 4 (10.3) 2 (3.0) 1 (2.9) Semiprofessional 1 (1.6) 2 (5.1) 1 (1.5) 0 (00) Professional 18 (29.6) 7 (17.9) 18 (27.3) 10 (29.4) No of children 4.86± ± ± ± Social class: High 12 (19.7) 7 (17.9) 1 (1.5) 2 (5.6) 0.03 Middle 11 (18) 6 (15.4) Low 14 (23) 10 (25.6) 13 (19.7) 15 (22.7) 3 (8.8) 14 (41.2) Very low 24 (29.3) 16 (41) 37 (56.1) 15 (44.1) Birth order: First 8 (13.1) 11 (28.2) 11 (16.2) 13 (38.2) 0.07 Last 4 (6.6) 1 (2.6) 6 (9.1) 1 (2.9) Middle 12 (19.7) 6 (15.4) 14 (21.2) 4 (11.8) Others 37 (60.7) 21 (53.8) 35 (53.0) 16 (47.1) Residence: Rural 49 (80.3) 30 (76.9) (42.4) 13 (38.2) 0.69 Urban 12 (19.7) 9 (23.1) 38 (57.6) 21 (61.8) Smoking status: Yes 10 (16.4) 5 (12.8) (19.7) 7 (20.5) No 51 (83.6) 34 (87.2) 53 (80.3) 27 (79.5) No of cigarettes/day 11.37± ± ± ± Years of education 9.65± ± ± ±

5 Mohamed R. Halawa, et al. 873 Table (5): Compare the statistical relation of non-depressed and depressed patients of both groups regarding BMI & diabetes related variables. Egyptian Yemenis Variable Non depressed (6 1 %) Depressed (39%) p Non depressed Depressed (66%) (34%) p Duration of DM (years) 5.99± ± ± ± HbA 1c 8.44± ± ± ± BMI (kg/m 2 ) 26.47± ± ± ± Complication: Yes 24 (39.3 %) 27 (69.2%) (56.1%) 17 (50%) 0.56 No 37 (60.7%) 12 (30.7%) 29 (43.9%) 17 (50%) Eye complications: Yes 8 (42.1) 11 (57.9) (57.1) 9 (42.9) 0.34 No 53 (65.4) 28 (34.6) 54 (68.4) 25 (31.6) Feet compilations: Yes 11 (47.8) 12 (52.2) (58.3) 10 (41.7) 0.19 No 50 (65.4) 27 (35.1) 52 (68.4) 24 (31.6) Renal compilations: Yes 3 (42.9) 4 (57.1) (50) 1 (50) No 58 (62.4) 35 (37.6) 65 (66.3) 33 (34) Heart compilations: Yes 1 (100) 0 (00) (75) 1 (25) No 60 (60.6) 39 (39.4) 63 (65.5) 33 (34.4) Impotence: Yes 2 (100) 0 (00) (100) 0 (00) No 59 (60.2) 39 (39.8) 63 (64.9) 34 (35.1) Cont. Oral therapy 35 (63.4) 20 (36.6) (71.4) 18 (28.6) 0.72 Insulin 10 (40) 15(60) 8 (36.6) 14 (63.4 Both therapies 16(80) 4 (20) 13 (86.6) 2 (14.4) Med.Comorbidities: Yes 34(55.7%) 21 (53.8) (48.5) 16 (52.9) 0.67 No 27(44.3) 18 (46.2) 31 (51.5) 18 (47.1) ACEI/ARBs: Yes 24 (60) 16 (40) (64.3) 15 (35.7) 0.7 No 37 (61.7) 23 (38.3) 39 (67.2) 19 (32.8) BBs: Yes 10 (71.4) 4 (28.6) (90) 1 (10) 0.09 No 51 (59.3) 35 (40.7) 57 (63.3) 33 (35.5) CCBs: Yes 10 (66.7) 5 (33.3) (88.9) 1 (11.1) 0.1 No 51 (60) 34 (40) 58 (63.7) 33 (36.3) Diuretics: Yes 15 (68.2) 7 (31.81) (43.8) 9 (56.2) 0.04 No 46 (59) 32 (41) 59 (70.2) 25 (29.8) Statins: Yes 7 (50) 7 (50) (57.1) 3 (42.9) 0.6 No 54 (62.8) 32 (37.2) 62 (66.7) 31 (33.3) Comparison between the depressed patients of both groups Tables (6,7). Table (6): Socio demographic data of depressed Egyptian and Yemeni diabetics with significant difference as regard residence where 76.9% of the depressed Egyptians participants were from rural areas and 61.8% of the depressed Yemeni participants were from urban areas; and years of educations where 8.7±6.41 years in depressed Egyptians and 6.35±7.07 years in their Yemeni counterparts. Table (7): Diabetes related variables between both depressed groups and it shows significant longer duration of diabetes among Egyptian participant. Table (8) & Fig. (1): Predictors of depression in both groups. In Egyptian diabetics, duration of diabetes (Odds ratio 1.291), number of cigarette per day (Odds ratio 1.23), being of low social class (Odds ratio 1.7), being a female (Odds ratio 1.5), and divorce (Odds ratio 1.2) were the risk factors for depression. While, Within Yemeni participates, birth order, using beta blockers, being a female (Odds ratio 1.9), and divorce (Odds ratio 1.6) were the risk factors for depression.

6 874 Transcultural Prevalence of Depression in Type 2 Diabetic Patients Table (6): Comparing both depressed Egyptians and Yemeni participants regarding socio demographic data. Variable Depressed Egyptian (39) Depressed Yemini (34) Age mean±sd 60.02± ± Sex: Male 15 (38.5) 9 (26.5) Female 24 (61.5) 25 (73.5) Religion: Muslim 30 (76.9) 34 (100) NA Christian 9 (23.1) 00 (00) Marital status: Married 20 (51.3) 16 (47.1) Single 2 (5.1) 4 (11.8) Divorced 8 (20.5) 7 (20.6) Widow 9 (23.1) 7 (20.6) Occupation: N (%) N (%) Jobless Unskilled 17 (43.6) 6 (15.4) 18 (52.9) 4 (11.8) Semiskilled 3 (7.7) 1 (2.9) Skilled 4 (10.3) 1 (2.9) Semiprofessional 2 (5.1) 0 (00) Professional 7 (17.9) 10 (29.4) No. of children 5.89± ± Social N%: High 7 (17.9) 2 (5.6) Middle 6 (15.4) 3 (8.8) Low 10 (25.6) 14 (41.2) Very low 16 (41) 15 ( 44.1) Birth order N%: First 11 (28.2) 13 (38.2) Last 1 (2.6) 1 (2.9) Middle 6 (15.4) 4 (11.8) Others 21 (53.8) 16 (47.1) Residence N%: Urban 30 (76.9) 13 (38.2) Rural 9 (23.1) 21 (61.8) Smoking N%: Yes 5 (12.8) 7 (20.5) No 34 (87.2) 27 (79.5) No of cigarettes/day 14.94± ± Years of education 8.7± ± Table (7): Comparing both depressed Egyptian and Yemeni participants regarding diabetes related variable. Duration of DM (yrs) A 1c p-value Egyptian Yemenis Test p-value 8.65± ± ± ±0.83 Complication: Yes 27 (69.2%) 17 (50.0 %) No 12 (30.8%) 17 (50.0% Eye complications : Yes 11 (28.2) 9 (26.5) No 28 (71.8) 25 (73.5) Feet compilations: Yes 12 (30.8) 10 (29.4) No 27 (69.2) 24 (70.6) Renal compilations: Yes 4 (10.3) 1 (2.9) No 35 (89.7) 33 (97.1) Heart compilations: Yes 0 (00) 1 (2.9) No 39 (100) 33 (97.1) Impotence: Yes 0 (00) 0 (00) No 39 (39.8) 34 (35.1) Oral therapy 20 (36.6) 18 (28.6) Insulin 15 (60) 14 (63.4) Both therapies 4 (20) 2 (14.4)

7 Mohamed R. Halawa, et al. 875 Table (8): Predictors of depression in Egyptians and Yemeni groups. Variable B.co Egyptian depressed p Odd s (95%CI) Depressed Yemeni B.co p Odd s (95%CI) Low Social class Female Divorced Cigerttes/day Duration of diabetes Birth order b-blocker use B.co: Beta coefficient. CI: Confidence interval. 1.7 ( ) 1.5 ( ) 1.2 ( ) 1.23 ( ) ( ) ( ) ( ) ( ) ( ) Low S.C Female Divorced Cig/day D. of DM Birth order BBs using 0.14 Depressed Egyptian odd s (95% CI) Depressed Yemeni odd s (95% CI) Fig. (1): (Predictors of Depression). Discussion Our results showed high prevalence of depression in type 2 diabetes mellitus in both Egyptian 39% and Yemeni 34% participants. Although it is statistically insignificant, it is higher than that reported in population based samples in the Arab world (19%) [14] and in the United Arab of Emirates (16%) [15]. Our results goes with studies which reported that the prevalence of depression in a binational border population with T2DM (South Texas vs. Northeastern Mexico) to be 39% and 40.5% respectively [16]. The mean age of depressed participants was 60.02± years in the Egyptian subgroup and 57.26± years in Yemenis. This result is consistent with those who found higher rate of depression among older diabetic population [17], as this may be due to social isolation, limited resources, poor physical health, and cognitive dysfunction [18]. Our result showed that female sex, Higher number of children, Low and very low socioeconomic levels and lower mean number of years of education were significantly predominant and associated with depression in both diabetic Egyptian and Yemeni participants, matching studies which found 65.9% of the depressed Emirati participants were females [15] and others reporting, in Egyptian general population number of children 3 is a protective factor, low level of socioeconomic status and low mean number of years of education was a precipitating factor for depression [20,21,22] and antagonizing others who found no difference between male and female as regard depression in diabetics [19]. Regarding marital status we found no impact on the prevalence of depression among the Egyptian diabetics with positive impact among Yemenis patients being higher in unmarried, this result supported by researchers who found higher rate of depression (36%) among unmarried, widowed and divorced [12,23] and others who claimed this to the low socioeconomic status that affect unmarried people [17]. Also we found that 43.6% and 52.9% from diabetic depressed Egyptian and Yemini respectively are jobless but this was statistically insignificant and this inconsistent with studies which revealed occupational hardships were a precipitating factor for depression [24]. Moreover,

8 876 Transcultural Prevalence of Depression in Type 2 Diabetic Patients we found the rate of nonsmokers was 87.2% in Egyptian and 79.5% in Yemeni, with high mean number of cigarettes smoked per day in both depressed groups, although not statistically significant in Yemeni and this agrees with previous researches [25]. As regard diabetes related variables, poor glycemic control was significantly associated with depression in both Egyptian and Yemeni participants and this goes with several studies which found higher A1c levels in depressed participant than non-depressed [26,27] and inconsistent with others who found no association between A1C and depression [22,28]. In Egyptian depressed diabetics we found significant higher duration of the disease with significant relation of depression to diabetic related complications. This result was consistent with researchers who found longer duration of diabetes in depressed patients [29,30]. Other studies clarified that poor glycemic control in depressed diabetics might be due to that the depression and psychological stress increase sympathetic nervous system activity, inflammatory, and platelet aggregation, and decrease insulin sensitivity, thereby contributing to poor glycemic control and increasing the risk of complications [31]. Furthermore, depression in diabetes is associated with poor adherence to diet, exercise, poor compliance with medications and poor self-care and hence increase incidence of complications [32]. Among Yemeni depressed diabetics, we found no significant relation between diabetes duration and incidence of diabetic complication with depression and This goes with who found no relation between diabetes duration, complication and depression [19,29]. This might be due to shorter duration in both depressed and non-depressed Yemeni diabetics. Our study showed 60% of the depressed Egyptian and 63.4% of Yemeni participants were maintained on insulin therapy, although this was not statistically significant, it reflected higher rate of insulin usage among depressed participants, which agreed with previous research [33,34], this explained by that patients viewed oral treatment as the least and insulin as the most burdensome treatment [35]. Antagonizing those found no correlation between insulin therapy and depression in an Iranian sample [36]. Furthermore, we found no impact of Medical co morbidities on depression in both diabetic depressed groups, which is consistent with previous studies [37,38] and opponent to others [17]. Regarding drugs for treatment of medical comorbidities, in both depressed groups (Egyptians and Yemenis) no statistical significance was found except the use of diuretics among Yemeni participants. This is inconsistent with researchers who found an association between depression score and antihyperlipidemics [15]. The association of diuretics with depression in our study could be due to polyuria as considered as more burden by diabetics. In our study, body mass index (BMI) was not correlated with depression in studied groups; this results in agreement with some studies [39] and inconsistent with others, who concluded that the occurrence of depression is strongly related to BMI [40,12]. Our finding could be due to the patients' perception of overweight/obesity, as this matter is not of importance among old type 2 diabetics. In our study, most of the depressed Egyptians were from urban areas (76.9%) and this consistent with those who found that Diabetic patients from urban areas had the greatest prevalence of depression which highlights a need for its management [41]. In contrast 61.8% of depressed Yemeni participants were from rural areas and this agreed with other studies that revealed high prevalence of depression among residents from rural China with diabetes than that among the general population [42]. Lastly, some risk factors for depression were more prominent in Egyptian participants such as low social class, number of cigarette per day and duration of diabetes, while birth order and beta blocker usage were more prominent in Yemeni participants and this goes with other studies [43]. So far, this is the first binational comparison study in two Arabic nations; the results showed high rate of depression in type 2 diabetic patients with a differential impact of various psychosocial factors. Conclusion: There is a high prevalence of depression among Egyptian and Yemeni type 2 diabetes patients with no statistical difference. The most common significant association of diabetes and depression are poor glycemic control, female gender and low socioeconomic status despite other different cultural impacts and behavior. Recommendation: With the energized commitment associated with the movement for global mental health, this is the ideal time to recognize the importance of depression in diabetes disability, morbidity, and mortality and to identify how to elevate mental health services within diabetes care. Screening for depression must be encouraged in all type 2 diabetic patients for early detection and management to avoid its impact on diabetes.

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