https://orcid.org/0000-0003-0517-247X
Abstract
Background
Depression and anxiety are among the most common mental health conditions globally that impact the lifestyle of affected individuals. Mental conditions and chronic diseases are linked to each other bidirectionally. Depression and anxiety with comorbid chronic conditions are often neglected or under-screened and possess challenges in treatment. This study aimed to know the frequency and determinants of depression and anxiety along with the severity level among common chronic communicable and non-communicable diseases.
Methods
We enrolled 200 healthy controls and 800 cases with equal number (n = 400) of patients with communicable and non-communicable diseases. Depression and anxiety were screened through Hamilton’s rating scale for depression and anxiety separately. We also measured the determinants of severe depression among patients with chronic diseases. Data was analyzed through SPSS version 23.
Results
We found higher frequency of depression (31% vs 11%; p=<0.001) and anxiety (13.25% vs 6%; p = 0.021) among cases as compared to healthy controls respectively. We found higher levels of depression among participants with non-communicable diseases as compared to communicable diseases (37.25% vs 24.75%; p < 0.05) respectively. Moreover, there was a higher frequency of anxiety in participants with communicable diseases as compared to those with non-communicable diseases, but the difference was non-significant (14% vs 12.5% p = 0.081). Among non-communicable diseases the highest percentage was found among individuals with cancer (67%), followed by diabetes (38%), cardiovascular diseases (33%) and respiratory disorders (11%). Among participants with communicable diseases, the highest percentage of depression was found in patients with Tuberculosis (29%) followed by HIV/AIDS (28%), Long COVID-19 (25%) and Hepatitis B/C (17%).
Conclusion
There is a significantly higher percentage of depression and anxiety among participants with chronic diseases. It calls for a comprehensive approach to patient care that incorporates mental health as a fundamental aspect of the treatment and management of chronic diseases. Understanding the predictors of severe depression across different chronic conditions helps in stratifying patients who may benefit most from integrated psychiatric and psychological interventions.
Figures
Citation: Abbas U, Hussain N, Tanveer M, Laghari RN, Ahmed I, Rajper AB (2025) Frequency and predictors of depression and anxiety in chronic illnesses: A multi disease study across non-communicable and communicable diseases. PLoS One 20(5): e0323126. https://doi.org/10.1371/journal.pone.0323126
Editor: Ramesh Athe,, Indian Institute of Information Technology, INDIA
Received: January 20, 2025; Accepted: April 2, 2025; Published: May 7, 2025
Copyright: © 2025 Abbas et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The data analyzed in manuscript is owned by Dow University of Health Sciences. The data can be obtained from irb@duhs.edu.pk for researchers who meet the criteria for access to confidential data.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Depression and anxiety are among the most common mental health conditions globally [1], affecting individuals across diverse ages, socioeconomic backgrounds, and geographical regions. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines depression as a mood disorder characterized by several symptoms that must be present for at least two weeks, such as depressed mood, loss of interest in activities, sleep disturbances, change in appetite etc. While anxiety in DSM-5 is described as a condition characterized by excessive worry and apprehension that occurs more days than not for at least six months. It can also be associated with several other symptoms, including restlessness, fatigue, difficulty in concentrating, irritability, muscle tension, and sleep disturbances [2].
An estimated 3.8% and 4% of the global population suffers from depression and anxiety respectively [3] with different prevalence rates across different regions rising as high as 34% in Pakistan [4]. These disorders contribute significantly to the global burden of disease, leading to impaired daily functioning [5] and substantial economic costs estimated at $382.4 billion [6]. The prevalence of depression and anxiety is not only rising in the general population but is also alarmingly high among individuals with chronic illnesses [7]. Genetic factors, inflammatory pathways, social factors, health behaviors, financial costs and the psychological stress of managing persistent symptoms among patients with chronic diseases contribute to this heightened vulnerability [7].
In high income countries, severity of anxiety and depressive symptoms was strongly associated with having chronic medical conditions such as diabetes, pulmonary disease, heart disease, and arthritis [7,8]. Studies indicated a prevalence of depression among in-patients was 12% [9] and in out-patients was 27.0% [10]. Chronic diseases and mental health disorders such as depression and anxiety are interconnected through shared inflammatory pathways that significantly impact both physical and psychological well-being [11]. Pro-inflammatory cytokines affect critical biological systems associated with the pathophysiology of depression. Raised IL-1, IL-6, and TNF-alpha which are common in chronic conditions such as diabetes, have bidirectional relationship, affecting neurotransmitter functions and mood regulation. In addition, administration of proinflammatory cytokines in cancer or hepatitis C therapies, has been found to induce depressive symptomatology [11].
Pakistan is facing a double burden of diseases, with communicable diseases (CD) at 40% [12] and non-communicable diseases (NCD) at 58% [13] which is a huge challenge. However, the prevalence of depression and anxiety remains underexplored, particularly in the context of chronic illnesses. Limited studies in the region suggest a moderately high prevalence of anxiety and depressive symptoms among adults with multimorbidity aged 30 years and above [14].
The present study seeks to provide an updated estimation of the prevalence of depression and anxiety among adults in Karachi, Pakistan, with a specific focus on individuals living with chronic illnesses. We have selected NCD’s such as Diabetes, CVD, Respiratory diseases, Cancers, and CD’s such as Tuberculosis, HIV/AIDS, Long COVID-19, Hepatitis B, and C based on their high prevalence and significant impact on public health in Pakistan. This research aims to generate actionable data to inform targeted public health strategies and clinical interventions to enhance patient outcomes, reduce healthcare costs, and foster more effective, integrated models of care for managing both mental and physical health conditions.
Methods
Ethical consideration
The study was conducted as per ethical guidelines of declaration of Helsinki. It was approved by the Institutional Review Board (IRB) of Dow University of Health Sciences (DUHS). The IRB approval reference number is IRB-2342/DUHS/Approval/2022–652. The participants were recruited in the study after written informed consent.
Study Description and setting
In this cross-sectional, we included a total of 1000 age and gender matched participants from Dow University Hospital (DUH), Karachi Pakistan from January 2024 to November 2024. The sample size was calculated from OpenEPI sample size calculator. With estimated prevalence of depression and anxiety 30% (±5%) and design effect (DEFF) of 3, the sample size appeared to be 969. However, we included a total of 1000 individuals in our study.
Recruitment of participants
Cases.
A total of 800 participants with age 20–60 years, female or male were included in the study after taking written informed consent. This group was categorized into two main sub-groups as follows.
I.Non-communicable disease group: These were 400 individuals with non-communicable diseases diagnosed with either Diabetes mellitus, Cardiovascular disorders (hypertension and chronic artery disease), respiratory disorders (Asthma, COPD) and cancers (lung, prostate, breast and colon). These individuals were previously diagnosed by physicians and recruited from the respective outpatients’ departments (OPDs) with each group having 100 participants matched for demographic characteristics.
II.Communicable disease group: There were 400 individuals with communicable diseases diagnosed with tuberculosis, HIV/AIDS, Long COVID-19 or hepatitis B/C with each group having 100 participants. These individuals were previously diagnosed by physicians and recruited from respective OPDs after matching demographic characteristics.
Admitted patients and those who were already diagnosed with depression and anxiety were excluded from the study. Those who were prescribed for any anti-depressive or anti-anxiety medicines in past were also excluded from the study.
Healthy (HC) group.
We included 200 healthy individuals who had none of the above diagnosed diseases. Healthy individuals were of age 20–60 years, either male or female genders. The participants of healthy group were attendants of the patients with the same exclusion criteria. The medical, para medical staff and medical students were excluded from the study.
Data collection.
In all participants, at the time of recruitment, demographic data regarding age, gender, marital status, monthly income, and level of education (literate or illiterate) was recorded. The clinical data was obtained separately for each disease type.
Assessment of depression and anxiety.
Hamilton Depression Rating Scale was administered to assess the presence of depression and its severity. The scale consists of 17 items and score ranges from 0 to 54 where 0–7 indicate no depression, 8–13 indicate mild depression, 14–18 indicate moderate depression and ≥ 19 indicate severe depression. The scale has been used to assess depression and its severity among multiple medical conditions [15].
Hamilton Anxiety Rating Scale was used to assess the presence of anxiety. This scale consists of 14 items with a total score range of 0–56, where 0–5 indicate no anxiety, 6–14 indicate mild anxiety, 15–28 indicate moderate anxiety and ≥ 29 indicate severe anxiety. This scale has also been used to assess anxiety and its severity among multiple medical conditions [16].
Data analysis.
Statistical analysis was carried out using the Statistical Packages for Social Sciences (SPSS) version 23. Mean and frequencies were calculated through simple statistical analysis. The Pearson Chi square test was used to compare categorical data. While the Mann-Witney T test was used to compare the median values. Multiple regression was used to know the predictors of severe depression and anxiety in each disease type. P values <0.05 with 95% CI were considered as significant.
Results
a. Demographic characteristics of study participants
We included 1000 individuals in our study. Out of those, 200 were healthy controls and 800 were patients with either non-communicable diseases (n = 400) or chronic infectious diseases (n = 400). There was no significant difference in age and gender between cases and controls (p > 0.05). We found a significant higher frequency of depression (248/800;31% vs 22/200;11%; p=<0.001) and anxiety (106/800;13.25% vs 12/200;6%; p = 0.021) among cases as compared to healthy controls respectively. The demographic characteristics of cases and healthy controls are compared in Table 1.
b. Frequency of depression and anxiety in communicable and non-communicable diseases
We further explored the differential frequency of depression and anxiety among different groups in our study. We found higher levels of depression among participants with non-communicable diseases as compared to communicable diseases (149/400; 37.25% vs 99/400;24.75%; p < 0.05) respectively. However, there was a higher frequency of anxiety in participants with communicable diseases as compared to those with non-communicable diseases, but the difference was non-significant (14% vs 12.5% p = 0.081; Fig 1).
The figure shows the distribution of anxiety and depression among healthy controls (n = 200), participants with communicable (n = 400) and non-communicable diseases (n = 400).
c. Disease wise distribution of depression among study participants
We compared the frequency of depression among individuals with different chronic disorders among communicable and non-communicable diseases. Among non-communicable diseases we found a higher percentage (38/100; 38%) of depression among diabetic patients followed by cardiovascular diseases (33/100; 33%), and respiratory disorders (11/100; 11%). The highest percentage of depression was found among individuals with cancers (67/100; 67%). The percentage distribution of depression among non-communicable diseases is given in Fig 2A.
A, non-communicable diseases (n = 149). B, communicable diseases (n = 99).
Among participants with communicable diseases, we found the highest percentage of depression among individuals with Tuberculosis (29/100; 29%) followed by HIV/AIDS (28/100; 28%), Long COVID-19 (25/100; 25%) and Hepatitis B/C (17/100; 17%). The percentage distribution of depression among communicable diseases is given in Fig 2B.
d. Disease wise distribution of anxiety among study participants
We also compared the frequency of anxiety among individuals with different chronic disorders among communicable and non-communicable diseases. Among non-communicable diseases, we found 11% (11/100) of anxiety among diabetic patients, and 9% (9/100) among patients with CVD. Individuals with respiratory disorders were found to have the highest percentage (17/100; 17%) of anxiety while among individuals with cancers, we found 13% (13/100). The percentage distribution of depression among non-communicable diseases is given in Fig 3A.
A, non-communicable diseases (n = 40). B, communicable diseases (n = 56).
Among participants with communicable diseases, we found the highest percentage of anxiety among individuals with Tuberculosis (22/100; 22%) followed by HIV/AIDS (19/100; 19%), Hepatitis B/C (9/100; 9%) and Long COVID-19 (6/100; 6%). The percentage of depression among communicable diseases is given in Fig 3B.
e. Association of severity of depression with non-communicable and communicable diseases
We further compared the severity of depression among participants with respect to communicable and non-communicable diseases. Among patients with non-communicable diseases, we found a total of 39 (26.17%) individuals with mild and 44 individuals (29.5%) with moderate depression. However, 66/149 (44.2%) were found to have severe depression (p = 0.0032). There were significantly higher cases of severe depression among participants with diabetes, cardiovascular disorders, cancers, tuberculosis and HIV/AIDS (p < 0.05; Table 2). No difference in severity of depression was reported among patients with respiratory disorders, Long COVID-19 and Hepatitis B/C (p value >0.05; Table 2).
f. Association of severity of anxiety with non-communicable and communicable diseases
Moving further, we assessed the severity of anxiety among participants with respect to communicable or non-communicable diseases. We found a total of 17 (34%) individuals with mild and 18 individuals (36%) with moderate anxiety. However, 15/50 (30%) were found to have severe anxiety among patients with non-communicable diseases (p = 0.29). We found significantly least mild cases of anxiety among HIV/AIDS patients (p = 0.03) while no significant association found in severity of anxiety with type of disease (p > 0.05; Table 3).
g. Predictors of severe depression among non-communicable and communicable diseases
We further explored the predictors of severe depression among participants with non-communicable and communicable diseases. Among patients with non-communicable diseases, in participants who had diabetes, we found increased age (OR = 1.932; p = 0.012), married (OR = 1.12; p = 0.001), being on insulin therapy (OR = 5.13; p = 0.004), high HbA1c (OR = 6.98; p = 0.001), more years since diagnosis of DM (OR = 4.56; p = 0.001) and presence of one or more diabetes related complications (OR = 5.512; p = 0.001) were strong predictors of having severe depression. For cardiovascular diseases, having male gender (OR = 2.19; p = 0.022), married (OR = 0.9; p = 0.011), hypertension (OR = 3.78; p = 0.032), and more years of diagnosis (OR = 2.13; p = 0.0043) were found to be predictors of severe depression. Moreover, male gender (OR = 2.31; p = 0.0021), having lung cancer (OR = 3.15; p = 0.0031), being on radiotherapy or chemotherapy (OR = 6.13; p = 0.001) were strong predictors of severe depression among cancer patients.
While exploring predictors of severe depression among patients with chronic communicable diseases, we found that increased age (OR = 1.98; p = 0.004); male gender (OR = 2.39; p = 0.014), having MDR/XDR TB (OR = 3.12; p = 0.001), having diabetes as comorbid (OR = 4.72; p = 0.001) were predictors of severe depression among tuberculosis patients. Participants with long COVID-19, we found female gender (OR = 1.78; p = 0.004), having more than 2 symptoms of long COVID-19 (OR = 4.38; p = 0.001) were predictors of severe depression among them.
Discussion
This study highlights the significant mental health burden among individuals with chronic diseases, demonstrating a contrast in the prevalence of depression and anxiety between those with chronic conditions and healthy controls. The frequency of depression was significantly higher among cases than controls (31% vs. 11%, p < 0.001), and a similar trend was observed for anxiety (13.25% vs. 6%, p = 0.021). These findings are consistent with previous studies which suggest that chronic disease conditions are associated with increased rates of mental health disorders due to the stress and lifestyle limitations they impose on individuals [14,17,18-19].
We found that depression was significantly more prevalent among patients with NCDs (37.25%) compared to those with CDs (24.75%). This could be attributed to the long-term, progressive nature of NCDs, which often come with debilitating symptoms, a decline in quality of life, and decrease in life expectancy [20,21]. Chronic management of diseases such as diabetes, cardiovascular diseases, and cancer can also induce significant psychological stress, leading to depression [22].
While the prevalence of anxiety was higher among individuals with CDs as compared to NCD patients (14% vs. 12.5%), however the difference was not statistically significant. This observation may reflect the acute stress and uncertainty caused by social isolation associated with infectious diseases, which can trigger anxiety [23].
Our study’s findings illustrate a distinct distribution of depression and anxiety across various chronic diseases, both communicable and non-communicable. Notably, NCD’s such as cancer exhibited the highest rates of depression (67%), a statistic that aligns with previous studies emphasizing the severe psychological impact of cancer diagnoses and treatments [24,25]. These treatments often involve prolonged suffering and uncertain prognoses, which can significantly deteriorate mental health. Similarly, diabetes and cardiovascular diseases showed substantial depression rates of 38% and 33%, respectively. The chronic nature of these conditions, coupled with the burden of ongoing management and potential complications, contributes to these elevated levels of depression [26,27]. A study on Pakistani population gave a strong correlation between depression and chronic diseases especially anemia and diabetes [28].
For CDs, tuberculosis and HIV/AIDS were notable for their high depression rates, at 29% and 28% respectively. The fear of contagion and the complexity of their treatment regimens can exacerbate mental health issues, reflecting findings from other studies that highlighted similar psychological burdens among these patient groups [29–31].
Mental health treatment regimens and the management of chronic diseases often interact in complex ways that can complicate treatment approaches, presenting additional challenges for holistic management. For example, Selective Serotonin Reuptake Inhibitors (SSRIs) used for depression can interact with anticoagulants used in cardiovascular disease, increasing the risk of bleeding [32]. Anti-tuberculosis drugs particularly isoniazid and linezolid significantly interact with anti-depressants, others may cause adverse psychiatric effects, and drugs like rifampicin can lower the efficacy of antipsychotics due to their enzyme-inducing properties further exacerbating psychiatric issues and complicating treatment [33]. Concurrent use of SSRIs can inhibit specific CYP450 enzymes, impacting the metabolism of some chemotherapeutic agents like tamoxifen [34].
Concerning anxiety, our findings indicate that respiratory disorders lead among non-communicable diseases with a 17% rate, likely due to the acute and chronic stress associated with breathing difficulties and the direct impact on physical autonomy [35]. Cancer patients also showed significant anxiety levels (13%), which may be influenced by the life-threatening nature of the disease and the intense treatment regimen involved.
Among communicable diseases, tuberculosis had the highest anxiety rates (22%), followed by HIV/AIDS (19%), Hepatitis B/C (9%) and Long COVID-19 (6%), which might be reinforced by the prolonged and isolating treatment required, adding to the existing literature that stresses the psychological effects of TB treatment [36]. Diseases such as tuberculosis and HIV/AIDS not only involve complex treatment regimens but also carry social stigmas that may contribute to heightened anxiety levels as supported by studies on the psychosocial impacts of infectious diseases like HIV/AIDS and tuberculosis [37–40].
Our analysis focused on identifying predictors of severe depression among individuals with chronic diseases. Among patients with NCDs, several key predictors of severe depression were identified. In diabetes advanced age, marital status, the requirement for insulin therapy, high HbA1c levels, longer disease duration, and the presence of complications were significantly associated with severe depression. These findings suggest that the burden of diabetes management, particularly with complications and poor glycemic control, may contribute to psychological distress. The increase in pro-inflammatory mediators can be a plausible link explaining the increased severity of depression among patients with glycemic control as supported by various studies [41–44].
For CVD being male, married, having hypertension, and a longer duration since diagnosis were predictors of severe depression. This might reflect the stress associated with managing long-term, life-threatening conditions which can adversely affect prognosis as evidenced in existing literature [45]. In patients with cancer, the male gender, undergoing chemotherapy or radiotherapy, and having lung cancer were strongly linked to higher rates of severe depression. A review article documented that, similar to diabetic pathophysiology, cancer occurrence and anticancer treatments also results in the pro-inflammatory cytokines-mediated inflammation, which dysregulates the HPA-axis activity that may result in depression-like behavior. Conversely, depression can also trigger HPA-axis activation that results in the downstream release of endogenous glucocorticoids which may cause depressive symptomatology [46]. The psychological impact of cancer diagnosis and treatment is well recognized [25,47]; however, our findings highlight the particularly intense impact of lung cancer and aggressive treatments, which may be due to the poor prognosis and high symptom burden associated with these conditions.
In the realm of communicable diseases, notable factors for TB were increased age, male gender, having multi-drug-resistant TB (MDR/XDR TB), and the presence of diabetes as a comorbidity were identified as predictors of severe depression. Interestingly, in long COVID-19 patients, factors such as being female and experiencing more than two symptoms of long COVID-19 were linked to severe depression. This could be due to the ongoing and uncertain nature of long COVID-19, which can lead to significant anxiety and stress, contributing to depressive symptoms
These findings underscore the necessity for healthcare providers to adopt a holistic approach in managing patients with chronic diseases, incorporating routine mental health assessments, especially for those identified at high risk for severe depression. For patients with diabetes, cardiovascular diseases, and cancer, regular screening for depression and tailored psychological interventions should be considered as part of standard care protocols. Similarly, for communicable diseases like TB and long COVID-19, addressing mental health needs is crucial, particularly considering the stigma and long-term symptoms associated with these conditions.
Conclusion
This study adds to the growing body of evidence that chronic physical health conditions are a significant predictor of mental health problems, particularly depression and anxiety. It calls for a comprehensive approach to patient care that incorporates mental health as a fundamental aspect of the treatment and management of chronic diseases. Understanding the predictors of severe depression across different chronic conditions helps in stratifying patients who may benefit most from integrated psychiatric and psychological interventions. This approach not only aims to improve quality of life but also enhances the effectiveness of disease management programs, ultimately reducing the overall healthcare burden.
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