Background  
Studies have shown that presence of depression and anxiety disorder in diabetics can worsen the disease outcome. There is lack of data on burden of depression and anxiety disorder among type 2 diabetics and their socio-demographic and clinical predictors from rural primary care settings of India.

Aim  
Current study aimed to assess the prevalence of anxiety and depression and to identify their associated factors in type 2 diabetics from the rural primary care settings of North India.

Method  
A observational cross sectional study was conducted among patients of type II diabetes attending NCD clinic at two Primary Health Centres in district Fatehgarh Sahib, Punjab. The instruments used included a semi-structured questionnaire to collect the socio-demographic profile and the details of the diabetes and its treatment and two validated questionnaires, PHQ-9 and GAD-7, to assess and screen for depression and anxiety disorder respectively.

Results  
Mean age of the study participants was 46.5±12.7 years with male to female ratio of 1:1.6. Overall, 51.1%( 95%CI 36.6%-60.8% and 42.6%(95%CI 28.6%- 50.6%) of the participants had anxiety and depression respectively. Factors found to be significantly associated with presence of anxiety were physical inactivity, higher BMI(&gt;28 Kg/m2), being alcoholic and smoker, having any co-morbid illnesses like hypertension and ischemic heart disease. For presence of depression, being female, physical inactivity, of older age(&gt;60 years), having co-morbid illnesses and having any complication like chronic kidney disease were significantly associated. Metabolic components found to be significantly associated with both anxiety and depressions were systolic blood pressure, fasting blood glucose and Hb1AC levels. 

Discussion  
The eight studies in India from both urban and rural populations were recently summarized in a systematic review. Of the six urban clinic-based studies, between ¼ and ⅓ of the participants with diabetes were depressed; however, these studies demonstrated great variability (highest was 84%, and lowest was 16.9%).The prevalence of depression in T2DM patients in our study (42.6%) was nearly similar to other studies (35-50%). 

There was no sex predilection for depression in our study. The diagnosis of T2DM and its poor understanding in rural areas may be an cause of stress causing anxiety and depression in these people. We found no statistically significant association between depression and duration of diabetes, glycemic control and microvascular complications, These findings implicate that the depression should be assessed in all patients with diabetes, irrespective of gender, duration of diabetes, glycemic control or presence/absence of microvascular complications.   
One of the limitation of the study was its cross-sectional design, so inference about causality between depression and diabetes or anxiety and diabetes cannot be made.   
To summarize, the present study found a significantly high prevalence of depression and anxiety disorder among patients with type 2 diabetes attending primary care in rural settings. Universal screening for depression and anxiety disorder should be done in all patients with type 2 diabetes. Future studies from India, should evaluate the effect of treatment of depression on glycaemic control, and also the effect of glycaemic control on depression.

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Prevalence and Determinants of Depression and Anxiety disorder among type 2 diabetics from rural Punjab, North India