diabetes is a chronic , debilitating disease that requires life - long treatment and greatly increases the risk of serious , long - term complications . offering the long - term monitoring and treatment needed is not easy for the health - care systems of sub - saharan africa , which are more focused on managing acute infections . sub - saharan region has been reported with a growing incidence of diabetes ; in which the number of diabetic people which was 7.1 million in 2003 , raised to 12.1 million in 2010 , and is projected to be 23.9 million with a prevalence of 3.7% in 2030 . in currently emerging studies comorbidity of mental health problems among diabetic patients , most commonly depression and anxiety has been reported . a person with depression might have frequent and persistent low mood , lost interest , a change in appetite , sleep , and motor activity . as well decreased energy , poor concentration / thinking capacity / decision - making , worthlessness , and sometimes death wish or attempt are common presentations . a higher rate of depression is found among diabetic people than the general population as stated in recent studies . depression among diabetic people has led to poor treatment adherence poor treatment outcome and consequently worsened quality of life . this coexistence of depression has a higher rate in low- and middle - income countries than high - income countries . in another way distinct , prevalence rates have been reported on depression among diabetic patients ; this includes higher figures of 59.8% , 5060% in asia , 54.1% in nepal , 45.2% in bangladesh to ( 25.335.4% ) in india , 17% in poland , and substantially lower rate of 11.2% in peru . there are a number of factors which are associated with cooccurrence of depression among diabetics ; these include women , non - married , older age , low socioeconomic , and higher body mass index ; besides that smoking habit , increased number of comorbidities , higher level of cholesterol , and poor glycemic control are also related with depression in contrary to most studies , a survey conducted at the united states reported that a baseline diabetic control is not an independent predictor for depressive disorder ; one more study from china reported that college level education and having a job were related to depression among diabetics . based on pubmed cited articles , in africa , we found the following studies . in maroc 41.2% , 27.8% , and 21.9% of major depression , persistent depressive disorder ( less form of depression for 2 or more years ) , and double depression ( both major depression and persistent depressive disorder ) were reported among diabetic patients , respectively ; whereas similar studies reported the prevalence of depression 34.4% in guinea and 27.8% in nigeria ; besides this , anxiety and suicidal behavior were reported among 58.7% of guinean and 6.3% of nigerian subjects . the factors associated with depression were similar with those reported from other continents that include low education , low socioeconomic status , older age , higher level of cholesterol , urban residence , being nonmarried , diabetic complications , and longer duration of follow - ups . another study in algeria found out that frequent occurrence of type - two diabetes was associated with depression . in ethiopia , there were over 1.33 million cases of diabetes in 2015 . according to pubmed indexed reports , less prevalence of depression was reported ( relative to other african nations ) with about 16.319.2% range . in general diabetes mellitus is becoming the emerging challenge to developing nations which can be complicated by the cooccurrence of depression . there are limited studies which showed the prevalence of depression and associated factors among people living with diabetes mellitus in sub - saharan region , particularly in ethiopia . the aim of this study was to determine the prevalence and associated factors among diabetes mellitus . hence , the findings might have vital to stakeholders and policy makers working in diabetic and psychiatric areas by showing its prevalence and the factors associated with it . a cross - sectional study was conducted at ayder referral and mekelle hospitals from july to september 2015 . the study was conducted at the city of mekelle , the capital of tigray region with a total population of more than 300,000 . there are three public hospitals in the city , and the study was conducted at two of them . the source population was all diabetic patients who have medical follow - up at mekelle city , and diabetic patients who had follow - up at ayder referral / mekelle hospital during the study period was study population . those patients with age 18 years and above with follow up for 6 months or more were included in the study . sample size and sampling technique was calculated with single proportion population formula , 34% level of depression , 95% confidence interval ( ci ) , and 5% margin of error . the sample size becomes 344 ; as the study population is < 10,000 , correction formula is employed ; thus with 10% nonresponse rate the final sample size is 244 . the data were collected using a pretested structured questionnaire developed in english and translated to local language by expertise . to assess comorbid depression and anxiety , beck depression inventory ii ( bdi ) and beck anxiety inventory ( bai ) tool were used , respectively . mild depression is a score of 1120 and moderate is scoring 2130 , whereas severe depression is a score of above 41 . score of 16 or more on bai tool indicate anxiety ; mild , moderate , and severe anxiety is a score of 815 , 1625 , and above 25 , respectively . one day training was given to orient data collectors and supervisor on the questionnaire to be used , the purpose of the study and how to approach respondents and obtain consent . data collectors ' capability to gather consistent and appropriate data were assured before the data collection period through role plays in the training and in the pretest . in addition , pretest on 5% of the sample size was carried out in a private clinic . during the data collection time , they were supervised daily . the data were coded , checked , cleaned , and entered into computers using software epi info ( this software was developed by centers for disease control and prevention - cdc , atlanta , usa ) and then exported into spss window version 20 for analysis ( spss was developed by international business machines corporation ; ibm corp . logistic regression was performed to assess the association between binary outcomes and different explanatory variables . bivariate analysis was first conducted for each potentially explanatory risk factor ; then , multivariate logistic regression analysis was done . p < 0.05 was considered statistically significant in this study . after obtaining ethical clearance from college of health sciences , mekelle university , study settings were informed through official letter ; and with their approval , the study was conducted . after discussing the purpose of the study , assuring informed consent , privacy , and confidentiality were kept . those subjects who were screened to be depressed or develop anxiety a cross - sectional study was conducted at ayder referral and mekelle hospitals from july to september 2015 . the study was conducted at the city of mekelle , the capital of tigray region with a total population of more than 300,000 . there are three public hospitals in the city , and the study was conducted at two of them . the source population was all diabetic patients who have medical follow - up at mekelle city , and diabetic patients who had follow - up at ayder referral / mekelle hospital during the study period was study population . those patients with age 18 years and above with follow up for 6 months or more were included in the study . sample size and sampling technique was calculated with single proportion population formula , 34% level of depression , 95% confidence interval ( ci ) , and 5% margin of error . the sample size becomes 344 ; as the study population is < 10,000 , correction formula is employed ; thus with 10% nonresponse rate the final sample size is 244 . the data were collected using a pretested structured questionnaire developed in english and translated to local language by expertise . to assess comorbid depression and anxiety , beck depression inventory ii ( bdi ) and beck anxiety inventory ( bai ) tool were used , respectively . score of 21 or more on bdi ii tool indicate depression . mild depression is a score of 1120 and moderate is scoring 2130 , whereas severe depression is a score of above 41 . score of 16 or more on bai tool indicate anxiety ; mild , moderate , and severe anxiety is a score of 815 , 1625 , and above 25 , respectively . one day training was given to orient data collectors and supervisor on the questionnaire to be used , the purpose of the study and how to approach respondents and obtain consent . data collectors ' capability to gather consistent and appropriate data were assured before the data collection period through role plays in the training and in the pretest . in addition , pretest on 5% of the sample size was carried out in a private clinic . during the data collection time , they were supervised daily . the data were coded , checked , cleaned , and entered into computers using software epi info ( this software was developed by centers for disease control and prevention - cdc , atlanta , usa ) and then exported into spss window version 20 for analysis ( spss was developed by international business machines corporation ; ibm corp . released 2011 . logistic regression was performed to assess the association between binary outcomes and different explanatory variables . bivariate analysis was first conducted for each potentially explanatory risk factor ; then , multivariate logistic regression analysis was done . after obtaining ethical clearance from college of health sciences , mekelle university , study settings were informed through official letter ; and with their approval , the study was conducted . after discussing the purpose of the study , assuring informed consent , privacy , and confidentiality were kept . those subjects who were screened to be depressed or develop anxiety were referred to psychiatry clinics . among the 264 study subjects , the mean age and standard deviation are 43.2  16.6 with a range of 1782 years ; also 135 ( 51.1% ) , 180 ( 68.2% ) , 87 ( 33% ) , 242 ( 91.7 ) are women , married , have no formal education , and orthodox christian by religion , respectively [ table 1 ] . socio demographic characteristics of diabetic patients , mekelle , north ethiopia , apr 2016 ( n=264 ) on the clinical data , from the total diabetic patients we interviewed , 146 ( 53% ) take injection , 23.5% have other chronic medical illness , and 22% of them are taking other medication for their chronic medical problems . those with mild to moderate depression were 87 ( 33% ) , moderate to sever 39 ( 14.7% ) , severe depression 6 ( 2.3% ) . the most severe depressive symptoms reported are lost interest in sex completely by 42 ( 15.9% ) , being too tired in 34 ( 12.9% ) , and severe sleep disturbance among 18 ( 6.8% ) [ table 2 ] . characteristics of depressive symptoms on bdi -ii tool among diabetic patients , mekelle city , north ethiopia , apr 2016 ( n=264 ) as well the prevalence of anxiety is 18.2% ( 95% ci : 14% , 23.9% ) ; mild anxiety among 82 ( 31% ) , moderate anxiety in 32 ( 14% ) , and severe anxiety among 11 ( 4.1% ) . furthermore , from the study participants according to mmas , 28% ( 95% ci : 22.7% , 33.1% ) has poor medication adherence . from which 32 ( 12.1% ) , 158 ( 59.8% ) , and 74 ( 28% ) has high , medium , and low level of adherence , respectively . multivariate regression shows that anxiety disorder ( aor = 10.52 , 95% ci ( 4.56 , 24.28 ) ) , poor medication adherence ( aor = 4.38 , 95% ci : [ 1.98 , 9.64 ] ) , and coexistence of other physical illness ( aor = 3.04 , 95% ci : [ 1.11 , 8.34 ] ) are risk factors for depression [ table 3 ] . multivariate analysis among different factors and depression among diabetic patients , mekelle , north ethiopia , apr 2016 ( n=264 ) our finding of depression among diabetic patients which is 17% is comparable with prior studies conducted at black lion hospital ( 16.3% ) , addis ababa , ethiopia ( 19% ) , and poland ( 17% ) . although it is higher than a study peru ( 11.2% ) . in general , our finding is smaller than distinct discoveries from maroc , guinea , nigeria , asia , nepal , bangladesh , and india . these distinctions can be due to the differences in sample size , sociodemographic condition , and others . this is supported by an earlier study which reported that in the primary health - care facility 50% of patients with depression have a comorbid anxiety disorder . this in turn can lead to increased medical service utilization , chronicity , worse treatment outcome , and multiple relapse of the illnesses . comparable prior meta - analysis declared that depressed patients across a wide array of chronic illnesses such as diabetes and heart disease had 76% greater odds of being non - adherent with their medications compared to patients who were not depressed . diabetic patients are more prone to other physical illnesses , and this condition is enabling factor for depression . this was also found out in prior studies at poland , china , india , and iran . almost one in six diabetic patients have depression which associates with coexisting anxiety , poor medication adherence , and other chronic medical illnesses . therefore , it is better to formulate a mechanism to detect and manage depression early .
background : coexistence of mental health problems on diabetes mellitus can result in poor management of the illness , poor adherence to treatment , and low quality of life . 
 therefore , it is highly crucial to assess these problems ; thus we carried out this study with the aim of determining the prevalence of depression and identifying related factors among diabetic patients at city of mekelle , north ethiopia.methods:hospital-based cross - sectional study was employed among 264 diabetic patients , and participants were selected through systematic random sampling technique . 
 we used local language versions of beck depression inventory - ii , beck anxiety inventory , and morisky 8 item medication adherence scale to assess the levels of depression , anxiety , and medication adherence , respectively . 
 socio - demographic and clinical factors were also assessed . 
 we accomplish data entry , cleaning , and analysis through statistical package for social sciences window 20 ; also the level of significance was determined using adjusted odds ratio ( or).results : the prevalence of depression among diabetic patients is 17% ( 95% confidence interval [ ci ] : [ 12.9% , 21.6% ] ) . 
 in addition , 28% and 18.2% has low medication adherence and comorbid anxiety , respectively . 
 we identify anxiety disorder ( aor = 10.52 , 95% ci : [ 4.56 , 24.28 ] ) , poor medication adherence ( aor = 4.38 , 95%ci : [ 1.98 , 9.64 ] ) , and coexistence of other physical illness ( aor = 3.04 , 95% ci : [ 1.11 , 8.34 ] ) as risk factors for depression.conclusions:depression is a common mental health problem among diabetic patients which is related to poor treatment adherence coexistence of other physical illness and anxiety disorder . 
 this emphasizes to formulate a mechanism for early detection and appropriate intervention .