Abstract
Depression and anxiety are highly prevalent among diabetics and may reduce their quality of life. However, data is limited on the prevalence of depression and anxiety among Egyptian diabetics. Therefore, we aimed to assess the prevalence of anxiety and depression and their association with different demographics and comorbidities among Egyptian diabetics. This multicentric cross-sectional study included 679 patients with diabetes in Fayoum, Egypt. We assessed the prevalence of depression and anxiety using the Hospital Anxiety and Depression Scale and collected socio-demographic characteristics with other relevant clinical variables. We used descriptive statistics to describe demographic characteristics and frequency of depression and anxiety. We applied logistic regression to measure the association between the different covariates and depression/anxiety. Of 679 diabetic patients, 65.4% were females, and 54.1% were above 50 years old. The median (IQR) age was 52 [43, 60]. Overall, 34.2% had depression, and 38% had anxiety. The results of multiple logistic regression suggested that age (odds ratio [OR] = 2.28, 95% confidence interval [CI] [1.54, 3.41]), neuropathy (OR = 2.25, 95% CI [1.38, 3.70]), sexual dysfunction (OR = 2.24, 95% CI [1.02, 4.96]), the presence of coma or spasm (OR = 2.82, 95% CI [1.44, 5.72]), and anxiety (OR = 3.15, 95% CI [2.21, 4.52]) were associated with increased risk of depression among diabetics. For anxiety, only the presence of depression was strongly associated with an increased risk of anxiety (OR = 2.99, 95% CI [2.12, 4.24]). Over one-third of Egyptian diabetics had depression and anxiety. Depression and anxiety may be associated with poor clinical outcomes in diabetics.
Keywords: anxiety, cross-sectional, depression, diabetes mellitus, prevalence
1. Introduction
Diabetes mellitus (DM) is the most common chronic endocrinal disorder with complex biopsychosocial conditions. The International Diabetes Federation declared that 537 million have DM, with 6.7 million mortality in 2021.[1] People with diabetes have a problem generating insulin and/or adequately utilizing the body’s insulin, leading to the accumulation of glucose in the blood, resulting in significant mortality and morbidity.
Diabetes is typically managed with medication, exercise, and a healthy diet. However, the ongoing demands of diabetes care, such as dietary restrictions, regular exercise, blood glucose monitoring, regular follow-up, symptom management, and constant monitoring for complications, may exacerbate diabetic patients’ stress. As a result, patients may experience depression and anxiety, which can seriously affect their health and overall quality of life.[2]
Counter-regulatory hormones such as glucocorticoids, growth hormones, and glucagon are activated during psychological stress, preventing insulin from functioning normally, and causing blood glucose levels to rise with higher susceptibility for complications.[3] Further, poor glycemic control and functional impairment caused by diabetes complications may induce or exacerbate depression and anxiety in diabetic patients.[4–6]
Depression can affect anyone; however, those with type 2 diabetes are at a higher risk than the general people. A previous study found that the prevalence of depression was 2 times higher in diabetic patients than in general people.[7] A recent meta-analysis including 248 studies reported that the prevalence of depression in patients with type II DM was 28% which was higher than the 5% demonstrated in the general population.[8]
In Middle East countries, including Egypt, There is under-diagnosis of DM, and subsequent under-treatment, as 1 in every 3 patients with diabetes is undiagnosed.[1] This is probably due to poor awareness of diabetes symptoms, poor living, and social stigma. There is a lack of data assessing anxiety and depression among the Egyptian population, particularly in Fayoum governorate. Therefore, this multi-center cross-sectional study in Egypt aimed to study the prevalence of anxiety and depression disorders among diabetics and the associated risk factors.
2. Materials and methods
2.1. Study design and participants
We performed a multicentric cross-sectional study in 5 hospitals including Fayoum health insurance hospital (tertiary hospital), Fayoum teaching hospital (tertiary hospital), Ibshaway central hospital (secondary hospital), Fayoum general hospital (secondary hospital), and Alzahraa hospital (private hospital) in Fayoum governorate, Egypt. We conducted the study from November 2020 to December 2020 to assess the prevalence of depression and anxiety among diabetic patients. Ethical approval was obtained from the faculty of medicine, Fayoum University and verbal consent was obtained from each participant. The study inclusion criteria was (1) male or female Egyptian patients (2) older than 18 years old (3) clinically diagnosed with type I or II DM. We excluded participants who did not complete the questionnaire. The study reporting adhered to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.[9]
2.2. Sample size
A sample of 384 individuals was considered a minimum sample under a 95% confidence interval, 50% response distribution, and 0.05 margin of error.
2.3. Data collection and handling
Data was collected using a convenience sample method. The questionnaire was distributed among participants who verified the inclusion criteria in hospitals that have diabetes clinics. Data were collected by the authors. After the data collection, we used Microsoft Excel for data representation. The results were translated into English and combined in 1 datasheet for analysis.
2.4. Instrument
The questionnaire consisted of 2 sections as follows: the first section was sociodemographic data, including participants’ age, gender, country, residence (urban/rural), educational level, and diabetes detailed profile. The second section is the Hospital Anxiety and Depression Scale (HADS), which is a valid and reliable self-rating scale that measures anxiety and depression in hospital settings. The HADS has 14 items; 7 to assess anxiety and 7 for depression. Each item is scored on a 4-point Likert scale (0–3). For each subscale, the possible scores range from 0 to 21, with a maximum score of 21. 0 to 7 is considered normal (free of anxiety or depression), 8 to 10 is considered borderline, and 11 to 21 is considered a case of anxiety or depression. We used the Arabic-validated version of the scale.[10]
2.5. Statistical analysis
RSTUDIO-2022.12.0-353 was used for data analysis. We used median and interquartile range to describe numerical variables, while numbers and percentages were used to describe categorical variables. We used simple logistic regression model to examine the different variables associated with anxiety and depression. A multiple logistic regression was applied to measure the adjusted associations for statistically significant covariates in each simple logistic regression model. Odds ratios (ORs) and 95% confidence intervals (CIs) were used as our effect size. We did not deal with any missing data. All P-values were two-sided. A P-value < .05 was considered statistically significant.
3. Results
3.1. Demographic characters of the study sample
A total 679 patients with DM were included with a median (IQR) age of 52 years (43, 60); 65.4% were females, and nearly half (54.1%) were above 50 years old. More than two-thirds (71.3%) had diabetes for <10 years, and 43.3% were treated with insulin therapy. The most common complications were painful peripheral neuropathy and retinopathy; approximately two-thirds (66.1%) had painful peripheral neuropathy, and one-third (33.4%) had retinopathy. More than half of the sample was hospitalized for having a noncontrolled high blood sugar, and 28.4% were in the hospital for regular follow-up. The complete data about the patients’ demographics and diabetes history are shown in (Table 1).
Table 1.
Demographic characteristics and diabetes profiles of Egyptian diabetics.
| Variable | Class | Population, n (%) |
|---|---|---|
| Gender (%) | Male | 235 (34.6) |
| Female | 444 (65.4) | |
| Age (median [IQR]) | 52.00 [43.00, 60.00] | |
| Diabetes duration | 10 years or less | 484 (71.3) |
| more than 10 years | 195 (28.7) | |
| Insulin therapy | No | 385 (56.7) |
| Yes | 294 (43.3) | |
| Others (%) | No | 321 (47.3) |
| Yes | 358 (52.7) | |
| Complications | ||
| Peripheral painful neuropathy (%) | Not present | 230 (33.9) |
| Present | 449 (66.1) | |
| Neuropathy (%) | Not present | 537 (79.1) |
| Present | 142 (20.9) | |
| Retinopathy (%) | Not present | 452 (66.6) |
| Present | 227 (33.4) | |
| Ever experienced footulcer (%) | Not present | 555 (81.7) |
| Present | 124 (18.3) | |
| Sexual dysfunction (%) | Not present | 640 (94.3) |
| Present | 39 (5.7) | |
| Diabetes complications present (%) | Complicated | 579 (85.3) |
| Not complicated | 100 (14.7) | |
| Number of complications (%) | 2 or more | 270 (39.8) |
| <2 | 409 (60.2) | |
| Other parameters | ||
| Reason for being in the hospital | Coma or spasm (%) | 51 (7.5) |
| Foot ulcer as a cause for hospitalization (%) | 42 (6.2) | |
| High blood sugar (%) | 393 (57.9) | |
| Regular follow-up (%) | 193 (28.4) | |
| Presence of Co-morbid hypertension | Not present | 329 (48.5) |
| Present | 350 (51.5) | |
| Hypertension duration in years (median [IQR]) | 7.00 [4.00, 11.00] | |
| Anxiety class (%) | Abnormal | 259 (38.1) |
| Normal or borderline | 420 (61.9) | |
| Depression class (%) | Abnormal | 232 (34.2) |
| Normal or borderline | 447 (65.8) | |
| Regular follow-up (%) | Not present | 486 (71.6) |
| Present | 193 (28.4) |
3.2. Frequency of anxiety and depression among the study participants
Among diabetic patients in our study, 34.2% (232 out of 679) had depression symptoms, while 38% (259 out of 679) had anxiety symptoms according to HADS in which depression or anxiety is indicated by score between 11 and 21. The complete data about the frequency of anxiety and depression among the patients are shown in Table 2.
Table 2.
Prevalence of anxiety and depression among Egyptian diabetics.
| Parameter | Anxiety | Depression | |||
|---|---|---|---|---|---|
| Normal or borderline (N = 420) | Abnormal (N = 259) | Normal or borderline (N = 447) | Abnormal (N = 232) | ||
| General demographics | |||||
| Gender | Male | 160 (68.1%) | 75 (31.9%) | 166 (70.6%) | 69 (29.4%) |
| Female | 260 (58.6%) | 184 (41.4%) | 281 (63.3%) | 163 (36.7%) | |
| Age | <50 years | 202 (64.7%) | 110 (35.3%) | 238 (76.3%) | 74 (23.7%) |
| >50 years | 218 (59.4%) | 149 (40.6%) | 209 (56.9%) | 158 (43.1%) | |
| Diabetes-related demographics | |||||
| Diabetes duration | <10 years | 309 (63.8%) | 175 (36.2%) | 335 (69.2%) | 149 (30.8%) |
| >10 years | 111 (56.9%) | 84 (43.1%) | 112 (57.4%) | 83 (42.6%) | |
| Insulin therapy | Yes | 171 (58.2%) | 123 (41.8%) | 202 (68.7%) | 92 (31.3%) |
| No | 249 (64.7%) | 136 (35.3%) | 245 (63.6%) | 140 (36.4%) | |
| Complications | |||||
| Peripheral painful neuropathy | Present | 262 (58.4%) | 187 (41.6%) | 269 (59.9%) | 180 (40.1%) |
| Not present | 158 (68.7%) | 72 (31.3%) | 178 (77.4%) | 52 (22.6%) | |
| Neuropathy | Present | 80 (56.3%) | 62 (43.7%) | 65 (45.8%) | 77 (54.2%) |
| Not present | 340 (63.3%) | 197 (36.7%) | 382 (71.1%) | 155 (28.9%) | |
| Retinopathy | Present | 126 (55.5%) | 101 (44.5%) | 128 (56.4%) | 99 (43.6%) |
| Not present | 294 (65%) | 158 (35%) | 319 (70.6%) | 133 (29.4%) | |
| Foot ulcer | Present | 69 (55.6%) | 55 (44.4%) | 81 (65.8%) | 43 (34.7%) |
| Not present | 351 (63.2%) | 204 (36.8%) | 366 (65.9%) | 189 (34.1%) | |
| Sexual dysfunction | Present | 19 (48.7%) | 20 (51.3%) | 19 (48.7%) | 20 (51.3%) |
| Not present | 401 (62.7%) | 239 (37.3%) | 428 (66.9%) | 212 (33.1%) | |
| Number of complications | One | 273 (66.7%) | 136 (33.3%) | 304 (74.3%) | 105 (25.7%) |
| Two or more | 147 (54.4) | 123 (45.6%) | 143 (53%) | 127 (47%) | |
| Other parameters | |||||
| Reasons for being in the hospital | Regular follow up | 119 (61.7%) | 74 (38.3%) | 141 (73%) | 52 (27%) |
| Coma or spasm | 25 (49%) | 26 (51%) | 18 (35.3%) | 33 (64.7%) | |
| Foot ulcer | 25 (59.5%) | 17 (40.5%) | 32 (76.2%) | 10 (23.8%) | |
| High blood sugar | 251 (63.9%) | 142 (36.1%) | 256 (65.1%) | 137 (34.9%) | |
| Presence of co-morbid hypertension | Present | 201 (57.1%) | 151 (42.9%) | 212 (60.2%) | 140 (39.8%) |
| Not present | 219 (67%) | 108 (33%) | 235 (71.9%) | 92 (28.1%) | |
This table shows classify the sample according to the levels of depression and anxiety into normal and abnormal/borderline.
Data in this table are represented as frequency (percentage).
3.3. Results of univariate analysis
Table 3 demonstrates the unadjusted associations of demographics and diabetes health-related variable with anxiety and depression. For depression, the significant associations included age, diabetes duration, the presence of peripheral painful neuropathy, neuropathy, retinopathy, sexual dysfunction, the presence of diabetes complications, coma or spasm, history of hypertension, the number of complications, and anxiety.
Table 3.
Univariate logistic regression for independent predictors of depression and anxiety among diabetics.
| Variable | Unit | Variables predicting depression | Variables predicting anxiety | ||||
|---|---|---|---|---|---|---|---|
| OR | 95% CI | P | OR | 95% CI | P | ||
| Gender | Male | Ref | |||||
| Female | 1.4 | [0.99;1.96] | .05518 | 1.51 | [1.08;2.11] | .015 | |
| Age | 50 or less | Ref | |||||
| Above 50 years | 2.4 | [1.74;3.39] | <.0001 | 1.26 | [0.92, 1.71] | .153 | |
| Diabetes duration | 10 years or less | Ref | Ref | ||||
| more than 10 years | 1.67 | [1.18;2.35] | .003557 | 1.34 | [0.95;1.87] | .0935 | |
| Insulin therapy | No | Ref | Ref | ||||
| Yes | 0.8 | [0.58;1.10] | .1677 | 1.32 | [0.96;1.80] | .08375 | |
| Peripheral painful neuropathy | Not present | Ref | Ref | ||||
| Present | 2.29 | [1.59;3.29] | <.0001 | 1.57 | [1.12;2.19] | .008855 | |
| Neuropathy | Not present | Ref | Ref | ||||
| Present | 2.92 | [2.00;4.27] | <.0001 | 1.34 | [0.92;1.95] | .1287 | |
| Retinopathy | Not present | Ref | Ref | ||||
| Present | 1.86 | [1.33;2.58] | .0002 | 1.49 | [1.08;2.07] | .01604 | |
| Ever experienced footulcer | Not present | Ref | Ref | ||||
| Present | 1.03 | [0.68;1.55] | .8947 | 1.37 | [0.92;2.03] | .1162 | |
| Sexual dysfunction | Not present | Ref | Ref | ||||
| Present | 2.13 | [1.11;4.07] | .022 | 1.77 | [0.92;3.38] | .08536 | |
| Diabetes complications present | Not complicated | Ref | Ref | ||||
| Complicated | 3.4 | [1.91;6.03] | <.0001 | 1.92 | [1.19;3.09] | .007478 | |
| Coma or spasm | Not present | Ref | Ref | ||||
| Present | 3.95 | [2.17;7.19] | <.0001 | 1.76 | [0.99;3.13 | .05216 | |
| Foot ulcer as a cause for hospitalization | Not present | Ref | Ref | ||||
| Present | 0.58 | [0.28;1.21] | .1481 | 1.11 | [0.59;2.10] | .7481 | |
| High blood sugar | Not present | Ref | Ref | ||||
| Present | 1.08 | [0.78;1.48] | .6558 | 0.82 | [0.60;1.12] | .206 | |
| Hypertention | Not present | Ref | Ref | ||||
| Present | 1.67 | [1.21;2.31] | .001738 | 1.55 | [1.14;2.12] | .005796 | |
| Depression | Normal or borderline | Ref | |||||
| Abnormal | – | – | – | 3.42 | [2.46;4.77] | .0001 | |
| Number of complications | <2 | Ref | Ref | ||||
| 2 or more | 2.57 | [1.86;3.56] | <.0001 | 1.68 | [1.22;2.30] | .001285 | |
| Regular follow up | Not present | Ref | Ref | ||||
| Present | 0.63 | [0.43;0.91] | .01276 | 1.01 | [0.72;1.43] | .9467 | |
| Anxiety | normal or borderline | Ref | |||||
| Abnormal | 3.42 | [2.46;4.77] | <.0001 | – | – | – | |
Significant (but unadjusted) associations were found between the risk of anxiety and several study variables, including gender, peripheral painful neuropathy, retinopathy, the presence of diabetes complications, coma or spasm, history of hypertension, depression, and the number of complications.
3.4. Results of multivariate analysis
We created 2 multiple logistic regression models to examine the covariates associated with depression (Fig. 1) and anxiety (Fig. 2) in diabetic patients. For the depression model, statistically significant covariates included age (OR = 2.28, 95% CI [1.54, 3.41]), neuropathy (OR = 2.25, 95% CI [1.38, 3.70]), sexual dysfunction (OR = 2.24, 95% CI [1.02, 4.96]), the presence of coma or spasm (OR = 2.82, 95% CI [1.44, 5.72]), and anxiety (OR = 3.15, 95% CI [2.21, 4.52]). For the anxiety model, only the presence of depression was a statistically significant predictor (OR = 2.99, 95% CI [2.12, 4.24]).
Figure 1.
Multivariate logistic regression for associations among variables and depression in diabetics.
Figure 2.
Multivariate logistic regression for associations among variables and anxiety in diabetics.
4. Discussion
Depression and anxiety are highly prevalent among diabetic patients, impairing their health and life quality. Recognizing mental health disorders and associated risk factors among diabetics will help healthcare providers deliver better care in such cases. Thus, this study assessed the prevalence of depression and anxiety among diabetic patients in Fayoum governorate, Egypt. Of 679 diabetic patients, 232 (34%) patients suffered from depression, and 259 (38%) patients suffered from anxiety. These results show a higher prevalence compared to a recently published study conducted in another Egyptian governorate in 2021.[11]
This variable prevalence could be explained by different study settings as the current study was conducted in secondary and tertiary and private hospitals that have high referral rates involving complicated cases while the study conducted in 2021 included patients from rural primary care units. Additionally, different measurement tools, sample size, and including only type II diabetes while our study included type I and II diabetes might have contributed to this discrepancy in prevalence.
In comparison to other studies in Middle East countries, prevalence of depression in the current study is nearly similar to a study carried out in primary health care centers in Bahrain that demonstrated 33.3% depression in patients with DM used that used HADS scale in screening possible depressive symptoms.[12] Another study conducted in Saudi Arabia revealed 34.8% depression prevalence among patients with type II DM. However, another study conducted in Palestine revealed depression symptoms in 40% of sample that is higher than our results. This could be explained by different study methodology.
In our study, the majority of patients who likely had depression were females, older than 50 years old, had diabetes for more than a year, had diabetic complications, had peripheral painful neuropathy, had neuropathy, had retinopathy, had sexual dysfunction, had 2 or more diabetic complications, had coma or spasm, with a history of hypertension, the number of complications, and anxiety. However, multivariate analysis revealed that age, neuropathy, sexual dysfunction, the presence of coma or spasm, and anxiety were the only significantly predictive factors of depression. In support of our findings, a meta-analysis included studies in Arab countries revealed higher risk of depression among females with diabetes compared to males.[13] Though, not all studies showed this gender disparity in depression.[14] Additionally, a meta-analysis by Groot et al,[15] included 27 studies and demonstrated that depression is significantly associated with diabetes complications, including neuropathy and sexual dysfunction. In contrast to our findings, they reported significant association between depression and diabetic retinopathy.
Anxiety, besides depression, is prevalent among diabetic patients as reported by multiple studies. In this study, more than one-third of study population (38%) had anxiety symptoms. This result conforms to other study findings conducted in Jordan[16] and South London King’s College Hospital,[17] that reported anxiety in 37.7%, 38.3% of their populations, respectively.
In 2019 Chaturvedi et al[18] conducted a study of 3170 diabetic patients from 15 countries. They found that 18% of the population was positive for anxiety. This result varies significantly from our result (38% for anxiety). Differences may be due to the use of the clinical interview method instead of the self-reporting questionnaire; interviews may show less biased results. Besides, they screened a large sample of the population in 15 countries that differ in their demographic characteristics from our country.
Regarding Anxiety, females showed a higher frequency of abnormal scores; this may be due to higher female dominance than males in our sample. Peripheral painful neuropathy, retinopathy, the presence of diabetes complications, coma or spasm, history of hypertension, depression, and number of complications were associated with higher risk of anxiety among diabetics. On the other hand, age and duration of D.M were not associated with higher anxiety levels. Though, the presence of depression was the only statistically significant predictor of anxiety on multivariate regression. Chaturvedi et al[18] showed similar results of anxiety predominance in females, but unlike our results, they showed correlations between the duration of diabetes and the development of different anxiety disorders.
Further studies are needed to investigate the cause-effect relationship between depression and diabetes. Multicenter longitudinal prospective cohort studies should be conducted using a systematic methodology to provide evidence of causality if DM causes depression or depression causes DM.
5. Strengthens and limitations
Our study showed strength points as we investigated the 2 crucial parameters of mental health affections (depression - anxiety). Although results will not be generalized to the whole country, they may give an idea about every governorate in the country when further screening of the remaining cities is conducted. Besides, we collected the complete-filled questionnaire only to avoid missing information, using a valid and reliable self-rating measuring tool to assess the degree of mental health affection.
However, our study had some limitations, like the cross-sectional study design, which cannot conclude the causality between the disease of concern (D.M.) and its mental health affection. The data collection tools were a self-reporting questionnaire; although it contains a valid measuring score, it may show a particular bias compared to the clinical interview. The study was carried out in single governorate. Thus our findings are difficult to be generalized to the whole population of Egypt.
6. Conclusion
Depression and anxiety among diabetics showed relatively high prevalence; nearly 4 of every 10 patients show anxiety, and nearly 3 of every ten patients show depression. Even borderline patients of anxiety and depression show high prevalence, predicting a high risk of developing anxiety and depression with further morbidity. Thus, patients with DM should be screened regularly for depression and anxiety foe better life quality.
Author contributions
Conceptualization: Mohamed Abd-Elgawad.
Investigation: Mohamed Abd-Elgawad, Gehad T. Genedy, Alyaa K. Madeeh, Moaz Khamis, Eman A. Abdullah, Marwa G. Mustafa, Youssef Soliman, Amira Mohamed Taha.
Methodology: Mohamed Abd-Elgawad, Nada K. Abdelsattar, Gehad T. Genedy, Alyaa K. Madeeh, Moaz Khamis, Mahmoud Ryaad, Eman A. Abdullah, Marwa G. Mustafa, Ahmed Assar, Abdullah M. Farhat, Youssef Soliman, Amira Mohamed Taha.
Project administration: Mohamed Abd-Elgawad.
Resources: Alyaa K. Madeeh, Wessam H. Hassaan.
Software: Mohamed Abd-Elgawad, Alyaa K. Madeeh, Mahmoud Ryaad, Wessam H. Hassaan, Eman A. Abdullah, Amira Mohamed Taha.
Supervision: Mohamed Abd-Elgawad, Abdullah M. Farhat.
Validation: Mohamed Abd-Elgawad, Moaz Khamis.
Visualization: Mohamed Abd-Elgawad, Nada K. Abdelsattar.
Writing – original draft: Mohamed Abd-Elgawad, Nada K. Abdelsattar, Gehad T. Genedy, Alyaa K. Madeeh, Moaz Khamis, Mahmoud Ryaad, Wessam H. Hassaan, Eman A. Abdullah, Marwa G. Mustafa, Ahmed Assar, Abdullah M. Farhat, Youssef Soliman, Amira Mohamed Taha.
Writing – review & editing: Mahmoud Ryaad, Wessam H. Hassaan, Marwa G. Mustafa, Ahmed Assar, Abhigan Babu Shrestha.
Abbreviations:
- CIs
- confidence intervals
- DM
- diabetes mellitus
- HADS
- Hospital Anxiety and Depression Scale
- ORs
- odds ratios
All patients agreed to participate in the questionnaire fulfillment. All patients agreed that the paper would be published as long as the privacy is concealed from the public.
R147, Committee no. 78, Faculty of Medicine, Fayoum University, Fayoum, Egypt, November 15, 2020.
The authors have no funding and conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Abd-Elgawad M, Abdelsattar NK, Genedy GT, Madeeh AK, Khamis M, Ryaad M, Hassaan WH, Abdullah EA, Mustafa MG, Assar A, Farhat AM, Soliman Y, Shrestha AB, Taha AM. Prevalence of depression and anxiety among diabetic patients in Egypt: A cross-sectional study. Medicine 2023;102:46(e35988).
Contributor Information
Mohamed Abd-Elgawad, Email: mohammed.mahmod87@gmail.com.
Nada K. Abdelsattar, Email: nk1267@fayoum.edu.eg.
Gehad T. Genedy, Email: ghdtaha62@gmail.com.
Alyaa K. Madeeh, Email: alyaakhaled6299@gmail.com.
Moaz Khamis, Email: mooaaz767@gmail.com.
Mahmoud Ryaad, Email: mm2957@fayoum.edu.eg.
Wessam H. Hassaan, Email: samhesham155@gmail.com.
Eman A. Abdullah, Email: ea6128767@gmail.com.
Marwa G. Mustafa, Email: marwaaslan410@gmail.com.
Ahmed Assar, Email: ahmed.assar52@gmail.com.
Abdullah M. Farhat, Email: am3760@fayoum.edu.eg.
Youssef Soliman, Email: youssefrefaat138@gmail.com.
Amira Mohamed Taha, Email: am7529@fayoum.edu.eg.
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