Anxiety, depression, and suicidal ideation among patients with non-communicable diseases versus the general population in Southern Tehran: a cross-sectional study

Anxiety, depression, and suicidal ideation among patients with non-communicable diseases versus the general population in Southern Tehran: a cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Anxiety, depression, and suicidal ideation among patients with non-communicable diseases versus the general population in Southern Tehran: a cross-sectional study Masih Hashemi, Pardis Zarepour, Sarmad Salehi, Yosra Azizpour, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8539851/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Non-communicable diseases are a major cause of illness and death globally, including in Iran. Although associations with mental health have been suggested, evidence from Iran is limited. This study compared 3 mental health outcomes in adults with and without NCDs in southern Tehran. Method This cross-sectional study used secondary data from a telephone-based health survey conducted in southern Tehran (May–September 2023). Adults aged ≥ 25 years were included, yielding a final weighted sample of 1,124 participants. NCD status (hypertension, cardiovascular diseases, dyslipidemia, and diabetes) was self-reported based on prior medical diagnosis. Mental health outcomes (anxiety, depression, suicidal ideation, and overall mental distress) were assessed using validated tools (GAD-2, PHQ-2, GHQ-28 (questions 23 and 25)(. Associations between NCDs and mental health outcomes were examined using multinomial logistic regression and linear regression models, adjusted for sociodemographic and socioeconomic variables. Results Overall, 22% (95% CI = 19.05–24.46) of participants reported at least one NCD. Mental distress scores were significantly higher among individuals with NCDs compared to those without (mean 3.60 (95% CI = 3.06–4.15) vs. 2.60 (95% CI = 2.40–2.80)), p = 0.001). NCD patients also had higher mean depression (1.49 vs. 1.03, p = 0.001) and anxiety scores (1.71 vs. 1.32, p = 0.002). Suicidal ideation was more prevalent among NCD patients (17.61% vs. 11.70%). Multinomial regression showed that participants with NCDs had increased odds of high depression (Adjusted Odds Ratio [AOR] = 2.97, 95% CI = 1.68–5.26), high anxiety (AOR = 2.32, 95% CI = 1.40–3.85), and high overall mental distress (AOR = 2.47, 95% CI = 1.47–4.13) compared to participants without NCDs. Linear regression showed significantly increased scores for overall mental distress (Adjusted β = 0.97, 95% CI = 0.44–1.50), depression (Aβ = 0.44, 95% CI = 0.18–0.70), anxiety (Aβ = 0.36,95% CI = 0.12–0.60), and suicidal ideation (Aβ = 0.19, 95% CI = 0.03–0.36) among NCD patients. Conclusion Adults living with NCDs show markedly higher levels of mental distress than those without these conditions, underscoring the importance of incorporating routine mental health assessment and support into NCD care in Iran. Non-communicable diseases mental health Depression Anxiety Suicidal ideation mental distress Introduction According to WHO, Non-communicable diseases (NCDs) account for 41 million deaths, which is equal to 71% of deaths around the world ( 1 ) .Since the Industrial Revolution, NCDs have had the greatest disease burden, and in 2021, NCDs accounted for 1.73 billion disability-adjusted life years (DALYs) worldwide ( 2 ). This situation is also reflected in Iran. NCDs account for 83.5% of all deaths and 78.1% of the burden of diseases in Iran ( 3 ). The loss of functionality in NCD patients occurs in different secondary conditions ( 4 ). In addition to these secondary conditions, mental health outcomes have also affected the quality of life of many NCD patients ( 5 ). There have been some studies on the association between NCDs and mental health outcomes. For example, a study revealed that the risk of suicide attempt was 5.54 times higher among patients with hypercholesterolemia compared to the general population ( 6 ). Also studies confirm a higher prevalence of depression among cardiovascular diseases (CVD) patients compared to non-patients and Anxiety and stress levels are higher in individuals with type 2 diabetes than in the general population ( 7 , 8 ). Although this association is somewhat accepted among clinicians, further studies are needed to be conducted for more information on this correlation ( 9 ). There is a little information about this association in the Iranian population. The aim of this study is to estimate the prevalence of mental health outcomes including depression, anxiety, and suicidal ideation, among individuals with four major NCDs – hypertension (HTN), CVD, dyslipidemia and diabetes – using data from a survey conducted in the general population of southern Tehran. Studies such as this research can be helpful to healthcare policymakers, so that they can prevent the further negative impacts of these mental disorders. Materials and Methods Study design and setting This cross-sectional study was based on a secondary analysis of data from a telephone-based survey conducted in the southern region of Tehran between May 22 and September 24, 2023, in three strata of southern Tehran province: South Tehran, Rey, and Eslamshahr. The Survey employed a stratified random sampling design with probability proportional to size (PPS) to achieve population representativeness. Sampling frames were constructed from landline telephone registers, and within each contacted household, one eligible adult was randomly chosen for an interview ( 10 ). The initial survey included 1,311 adults aged 18 years and older. For this secondary analysis focusing on NCDs, the sample was restricted to participants aged 25 years or older, leading to the exclusion of 135 individuals under the age of 25. Further exclusions were applied for a history of cancer (n = 7) and missing data on mental health outcomes (n = 28), wealth index (n = 8), insurance status (n = 7), and employment status (n = 2). This process yielded a final analytic sample of 1,124 individuals. Data Collection and Measurements Data used in this study were collected by trained interviewers. The Questionnaire’s validity was checked by public healthcare experts for simplicity and clarity. To further check the content validity of the checklist, content validity ratio (CVR) and content validity index (CVI) were measured. After receiving the CVR and CVI of items in the questionnaire, it was readjusted so that all items have reached the accepted level( 10 ). NCDs NCDs analyzed in this study were HTN, CVD, dyslipidemia, and diabetes. Each of these diseases was assessed based on the question: "Has a doctor or healthcare provider ever told you that you have this condition?" Participants who answered "yes" to having any of these diseases were classified into the NCD group. Mental Health Outcomes This research studied three mental health outcomes—anxiety, depression, and suicidal ideation—which were assessed using six questions. Anxiety and depression were measured by validated and adjusted tools like Generalized anxiety disorder (GAD-2) and the Patient Health Questionnaire-2 (PHQ-2) ( 11 , 12 ). Each mental health outcome was assessed using two questions on a four-point scale. The responses were scored and summed to create a composite score for each condition: 0 = Not at all, 1 = several days, 2 = More than half the days, 3 = nearly every day. For suicidal ideation, 2 questions (questions 23 and 25) from General Health Questionnaire (GHQ 28) were used and scores were given based on the answers from the respondent. The questions were “In the last month, have you felt that life is completely hopeless” and “In the past month, have you considered whether you want to end your life?” Mental distress was operationalized both as a composite outcome and as separate subdomains. The composite mental distress score was created by summing three variables: depression, anxiety, and suicidal ideation. Each subdomain (depression, anxiety, and suicidal ideation) was also analyzed separately as an outcome. The continuous scores for depression, anxiety, and mental distress were converted into ordinal variables with three levels ("Low," "Moderate," "High") using tertile splits. Suicidal ideation was binary-categorized as either "Low" or "High”. Sociodemographic factors The sociodemographic factors analysed in this study were age (< 60, 60≥), sex (Male or Female), area of residence (Urban or Rural), insurance (with or without health insurance), socioeconomic status (Low, Middle or High), marital status (single, married, divorce/widow), Employment status (Unemployed, employed and Retired), Education level(Illiterate and elementary, Under Diploma, Diploma and Collegiate) and whether the respondents received medical services from public healthcare centers in the last year or not. Socioeconomic status was assessed using the question: “Which of the 5 socioeconomic classes, if the whole Iranian population were divided into them, would your family be in” Respondents selected one of five options: high, above average, average, below average, or low. Based on these responses, participants were classified into three categories: low (low and below average), middle (average), and high (high and above average). Statistical analysis The characteristics of the study were summarized using descriptive statistics. For categorical variables, we report proportions (percentages) and 95% confidence intervals. Mental distress and its subdomains were considered as dependent variables (outcomes), while non-communicable disease (NCD) status was treated as the main independent variable (exposure). Binary logistic regression was applied for dichotomous outcomes, including suicidal ideation. Multinomial logistic regression was used for outcomes with more than two categories, including stress, depression, and overall mental health outcome. For the adjusted model, variables were selected using backward selection approach with a retention criterion of P < 0.20. All statistical analyses were performed using STATA software (version 17). The dataset was weighted in accordance with the age and sex composition of Tehran’s population, as documented in the 2016 Iranian census, to enhance the representativeness of the sample of Tehran. A p-value < 0.05 was considered statistically significant. Results A total of 1124 participants were identified. The mean age of the study population was 43.47 years ± 0.49 (95% CI = 42.41–44.32), and 51% (95% CI = 47.78–54.13) were male. Overall, 22% (95% CI = 19.05–24.46) of respondents had one or more NCDs. NCDs include Diabetes (n = 80), CVD (n = 40), HTN (n = 107), dyslipidemia (n = 97). Table 1 depicts baseline characteristics based on NCDs. around 57.66% (95% CI = 50.28–64.71) of those with NCDs are female, while 46.66% (95% CI = 43.12–50.18) of those without NCDs are female. Regarding Marital status, 2.09% (95% CI = 0.76–5.62) of those with NCD are single, while among participants without NCDs, this number is 10.59% (95% CI = 8.51–13.11). In terms of education, it’s seen that among individuals without NCDs, Diploma and Collegiate have the highest percentages, respectively with 33.89% (95% CI = 30.65–037.28) and 31.76% (95% CI = 28.52–35.19) of respondents without NCDs, and for NCD patients these percentages are respectively 21.23% (95% CI = 15.93–27.72) and 17.84% (95% CI = 12.87–24.21). In contrast, we can see that 42.29% (95% CI = 35.45–49.43) of the participants with NCDs are illiterate or have elementary education, while this number is 17.31% (95% CI = 14.67–20.31) in individuals without NCDs. 63.77% (95% CI = 56.69–70.29) of patients with NCD have received medical services from a healthcare center in the last year. In comparison, 46.89% of non-NCD respondents received medical services from a healthcare center during the same period of time. Table 1 Baseline characteristics based on NCDS (Column) Variables Non-communicable diseases Total (n = 1124) No (n = 899) Yes (n = 225) % (95% CI) % (95% CI) N Age group (Years) Under 60 92.38 (90.10, 94.17) 58.72 (51.50, 65.59) 991 Over 60 7.62 (5.83, 9.90) 41.28 (34.41, 48.50) 133 Sex Male 53.34 (49.82, 56.82) 42.34 (35.29, 49.72) 445 Female 46.66 (43.18, 50.18) 57.66 (50.28, 64.71) 679 Marital status Single 10.59 (8.51, 13.11) 2.09 (0.76, 5.62) 85 Married 85.72 (82.96, 88.10) 77.50 (71.02, 82.88) 965 Divorced/widow 3.69 (2.57, 5.28) 20.41 (15.28, 26.71) 74 Employment status Unemployed 42.37 (38.99, 45.83) 56.56 (49.27, 63.58) 607 Employed 52.01 (48.45, 55.54) 25.18 (19.37, 32.04) 451 Retired 5.62 (3.95, 7.95) 18.26 (12.93, 25.14) 66 Education level Illiterate and elementary 17.31 (14.67, 20.31) 42.29 (35.45, 49.43) 233 Under Diploma 17.04 (14.51, 19.91) 18.64 (13.91, 24.53) 208 Diploma 33.89 (30.65, 37.28) 21.23 (15.93, 27.72) 371 Collegiate 31.76 (28.52, 35.19) 17.84 (12.87, 24.21) 312 Residency Rural 5.47 (4.42, 6.75) 4.86 (3.13, 7.47) 121 Urban 94.53 (93.25, 95.58) 95.14 (92.53, 96.87) 1003 Socio-economic status Low 59.47 (55.94, 62.90) 60.75 (53.62, 67.45) 649 Middle 35.69 (32.40, 39.13) 35.33 (28.83, 42.43) 425 Good 4.84 (3.43, 6.79) 3.91 (2.03, 7.43) 50 Basic insurance No 23.65 (20.66, 26.92) 15.30 (10.92, 21.02) 233 Yes 76.35 (73.08, 79.34) 84.70 (78.98, 89.08) 891 Refer to healthcare center in the past year No 46.89 (43.34, 50.47) 63.77 (56.69, 70.29) 544 Yes 53.11 (49.53, 56.66) 36.23 (29.71, 43.31) 580 Percentages are column-wise Table 2 presents the mean scores of mental health outcomes and the prevalence of mental distress, comparing participants with and without NCDs. The mean mental distress score in participants with NCDs is reported as 3.60 (95% CI = 3.06–4.15) while this score is 2.60 (95%CI = 2.40–2.80) among respondents without any NCD, these difference are statically significant (p value = 0.001). Additionally, the mean of depression score was 1.03 (95% CI = 0.94–1.12) among individuals without NCDs. in comparison, this score was 1.49 (95% CI = 1.24–1.74) among NCD patients and these differences are statically significant (p value = 0.001). In anxiety, 9.11% (95%CI = 7.33–11.26) of individuals without NCDs experience high levels of anxiety and among the individuals with NCDs, this percentage is 15.14% (95% CI = 10.79–20.84). High levels of suicidal ideation were seen in 11.7% (95% CI = 9.62–14.16) of individuals without NCDs while 17.61% (95% CI = 13.13–23.20) of participants with NCD experienced this level of suicidal ideation. Table 2 Prevalence of Mental distress mood based on having at list one of the NCDS Variables NCDS P value No Yes Mental distress Score: mean ( 95%CI ) 2.60 (2.40, 2.80) 3.60 (3.06, 4.15) 0.001 Depressive mood score: mean ( 95%CI ) 1.03 (0.94, 1.12) 1.49 (1.24, 1.74) 0.001 Anxious mood score: mean ( 95%CI ) 1.32 (1.23, 1.41) 1.71 (1.47, 1.94) 0.002 Suicide thoughts mean ( 95%CI ) 0.25 (0.19, 0.31) 0.40 (0.24, 0.56) 0.080 Anxiety % (95% CI) Low 59.53 (56.00, 62.95) 45.93 (38.93, 53.10) 0.001 Moderate 31.36 (28.17, 34.74) 38.92 (32.28, 46.00) High 9.11 (7.33, 11.26) 15.14 (10.79, 20.84) Depression % (95% CI) Low 48.02 (44.47, 51.60) 38.03 (31.36, 45.19) < 0.001 Moderate 45.58 (42.04, 49.16) 47.48 (40.47, 54.60) High 6.40 (4.91, 8.29) 14.48 (10.16, 20.23) Suicidal ideation % (95% CI) Low 88.30 (85.84, 90.38) 82.39 (76.80, 86.87) 0.021 High 11.70 (9.62, 14.16) 17.61 (13.13, 23.20) Mental distress % (95% CI) Low 43.02 (39.52, 46.59) 30.95 (24.72, 37.97) 0.002 Moderate 43.35 (39.85, 46.92) 47.07 (40.05, 54.20) High 13.63 (11.40, 16.22) 21.98 (16.79, 28.24) CI: Confidence interval NCDs: Non-communicable diseases Statically significant p values are bolded. Percentages are column-wise. The Table 3 shows logistic regression analysis for the association between NCDs status and mental distress as an outcome. Patients with NCDs had 2.97 times odds of experiencing high levels of depression compared to low levels than those without NCDs (AOR = 2.97, 95% CI = 1.68–5.26). Table 3 Logistic Regression Analysis for the Relation between NCDs Status and Mental disorder (as an outcome) Suicidal ideation AOR (95%CI) P value 1.97 (1.22, 3.21) 0.006 Depression Moderate vs. Low High vs. Low AOR (95%CI) P value AOR (95%CI) P value 1.61 (1.07, 2.42) 0.021 2.97 (1.68, 5.26) < 0.001 Anxiety Moderate vs. Low High vs. Low AOR (95%CI) P value AOR (95%CI) P value 1.35 (0.92, 1.99) 0.124 2.32 (1.40, 3.85) 0.001 Mental distress Moderate vs. Low High vs. Low AOR (95%CI) P value AOR (95%CI) P value 1.68 (1.09, 2.59) 0.020 2.47 (1.47, 4.13) 0.001 AOR: Adjusted for: Age, Sex, Marriage status, Residence, Wealth index, Insurance, Refer to healthcare center, Job, Education Statically significant p values are bolded. CI: Confidence interval Similarly, individuals with NCDs have 132% higher odds of experiencing high levels of anxiety compared to those without NCDs (AOR = 2.32, 95% CI = 1.40–3.85). Consistently, the odds of reporting high versus low levels of mental distress are also higher in the NCD group (AOR = 2.47, 95% CI = 1.47–4.13) compared to the group without NCDs. Linear regression analysis for association between NCDs status and mental distress showed in Table 4 . The mental distress score is, on average, 0.97 units higher among patients with NCDs compared to those without NCDs (adjusted β = 0.97, 95% CI = 0.44–1.50). The depression score of patients with NCDs is, on average, 0.44 units higher than that of their non-NCD counterparts (Aβ = 0.44, 95% CI = 0.18–0.70). For suicidal ideation, the mean score among individuals with NCDs is 0.19 units higher compared to participants without NCDs (Aβ = 0.19, 95% CI = 0.03–0.36). Table 4 linear Regression Analysis for the Relation Between NCDs Status and Mental distress (as an outcome) Outcome Model 1 Model 2 Model 3 β (95%CI) P value Aβ (95%CI) P value Aβ (95%CI) P value Mental distress score 1.00 (0.42, 1.58) 0.001 0.99 (0.42, 1.57) 0.001 0.97 (0.44, 1.50) < 0.001 Depressive mood score 0.46 (0.19, 0.73) 0.001 0.44 (0.18, 0.71) 0.001 0.44 (0.18, 0.70) 0.001 Anxious mod score 0.38 (0.14, 0.63) 0.002 0.34 (0.08, 0.59) 0.011 0.36 (0.12, 0.60) 0.003 Suicide thoughts score 0.15 (-0.2, 0.32) 0.080 0.21 (0.04, 0.37) 0.012 0.19 (0.03, 0.36) 0.018 Model 1: Crude Model 2: Adjusted for age, sex Model 3: Adjusted for: Age, Sex, Marriage status, Residence, Wealth index, Refer to healthcare center, Job, Education Statically significant p values are bolded. CI: Confidence interval A-beta (Aβ): Adjusted beta coefficient Discussion Our findings indicate that, on average, individuals with NCDs experience higher levels of mental distress and anxiety compared to those without NCDs. Depression was also more prevalent in this group. These findings point to an association between the presence of NCDs and poorer mental health outcomes. As mentioned above, mental distress emerges in higher levels in NCD patients. Our data showed a 1-unit increase in mental distress score of NCD patients compared to those without NCDs. This increase in mental distress score is consistent with other studies, as one study in the Netherland that was conducted on 1,788 chronically medical ill Dutch patients, concluded that chronically patients with illnesses have more mental distress than the normal population as they scored higher on the GHQ questionnaire by around 1 unit ( 14 ). Another study in northern Ethiopia region showed that the prevalence of mental distress is nearly double in NCD patients (62.0% vs 35.1%) ( 15 ). Increased mental distress can be a result of functional limitation and reduced daily activity in NCD patients, impairment of mobility and social participation leads for frustration and also mental distress. NCDs might also reduce the social support of the patient, which can worsen the mental distress ( 16 ). Furthermore, a significant association was found between NCDs and anxiety, with the prevalence being 6% higher among individuals with NCDs compared to those without NCDs (15.14% vs. 9.11%).This means that anxiety is more visible in NCD patients compared to the general population. This finding is supported by other studies, for example, a case-control study of 996 type 2 diabetes patients and 2,145 individuals without diabetes in Brazil, found that 34.1% of patients had generalized anxiety disorder in comparison to 21.8% of general population, showing an increased prevalence of depression in diabetes patient ( 17 ). Another cross-sectional study conducted across 42 countries, also found that having one chronic condition increases the risk of showing anxiety symptoms by around 100% with an OR of 1.94 ( 18 ). The reason for this anxiety has been discussed in psychological and physiological ways. One psychological mechanism is that the fear of the NCD’s progression or even their worsening might cause the anxiety in these patients ( 19 ). The physiological theory for this contribution is about inflammatory responses that are common in different NCDs as Interleukin-6 (IL-6) has been seen to have a mediating role in anxiety ( 20 ). It can also be concluded from this study, that depression is more frequently in NCD patients since the odds of depression are 3 times higher in them (AOR = 2.97). A systematic review and meta-analysis of 83 studies in South Asia reported high pooled prevalence rates of depression among patients with diabetes (40%), stroke (39%), and hypertension (38%), alongside a pooled anxiety prevalence of 29% ( 21 ). another meta-analysis of 40 studies found a pooled odds ratio of 3.1 for depression and anxiety among individuals with chronic diseases, including diabetes, obesity, cancer, chronic obstructive pulmonary disease (COPD), and heart disease ( 22 ). There are many suggested explanations for this association. One proposed mechanism for this association involves insulin resistance. This theory posits that impaired insulin signaling can lead to neuroinflammation, which in turn damages neurons and alters brain function to induce depressive symptoms. For instance, pro-inflammatory cytokines, which are elevated due to disrupted glucose metabolism, can lead to reduced serotonin levels ( 23 ). Implications for Public Health The association suggested by this article and similar ones can be implicated in clinical and public health levels. Clinicians can consider routine mental health screening for their NCD patients to minimize the impact of the mental health outcomes on their life quality. In the public health level, a high burden of disease can be resulted by the mental health outcome, setting aside the burden caused by the NCD itself. Future studies on this matter can be focused on finding a physiological mechanism for this association in cellular and systemic levels, or suggested medical treatments to stop or control these outcomes in order to lessen the burden caused by them. A public health approach to this finding can be providing the facility for mental health screening in general hospitals to limit the burden caused by these mental health outcomes. Strengths and limitations The strengths of this study include a relatively large sample size and a representative population. The limitations of this study were the self-reported status of our data and the nature of cross-sectional studies that restricts casual interference. Conclusion The findings of this study show that people living with major non-communicable diseases face noticeably greater emotional and psychological strain than those without such conditions. Higher levels of anxiety, depressive symptoms, suicidal thoughts, and overall mental distress were all more common in the NCD group. These results point to an important gap in current care: routine mental health assessment and support should be incorporated into NCD management programs in Iran to help reduce the added burden these conditions create. Abbreviations NCD Non-communicable disease GAD-2 Generalized Anxiety Disorder-2 PHQ-2 Patient Health Questionnaire-2 GHQ-28 General Health Questionnaire-28 CI Confidence interval AOR Adjusted odds ratio A-beta (Aβ) Adjusted beta coefficient WHO World Health Organization DALYs Disability-adjusted life years CVD Cardiovascular disease PPS Probability proportional to size CVR Content validity ratio CVI Content validity index HTN Hypertension STATA Data analysis and statistical software COPD Chronic obstructive pulmonary disease Declarations Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the ethics committee of Tehran university of Medical Sciences, Tehran, Iran (NO. IR.TUMS.MEDICINE.REC.1400.599).As the survey was conducted by telephone, verbal informed consent was obtained from participants before data collection. Participants were informed of the study aims, assured of data confidentiality, advised of voluntary participation and their right to skip any question, and informed about the approximate length of the interview. Consent for publication Not applicable. Clinical Trial Number not applicable Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests Not applicable Funding This research received no specific grant from any funding agency. Acknowledgments The authors extend their gratitude to the Deputy of Health at Tehran University of Medical Sciences (TUMS) for their partnership. During the preparation of this manuscript, the authors used OpenAI's ChatGPT and DeepSeek AI to assist with language editing, which improved the clarity and coherence of the text. Author Contributions S.A. conceptualization; P.Z. methodology, formal analysis, and data curation; M.H. writing - original draft; S.S., Y.A., and M.K. writing - review and editing; Y.A. project administration; M.K. supervision. References WHO. Noncommunicable diseases 2025 [Available from: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases Li J, Pandian V, Davidson PM, Song Y, Chen N, Fong DYT. Burden and attributable risk factors of non-communicable diseases and subtypes in 204 countries and territories, 1990–2021: a systematic analysis for the global burden of disease study 2021. Int J Surg. 2025;111(3):2385–97. Rahimi E, Mohammadi R, Mokhayeri Y, Nazari SS. Gender disparity and risk of noncommunicable disease among adults in Islamic Republic of Iran. East Mediterr Health J. 2023;29(8):630–7. Prynn JE, Kuper H. Perspectives on Disability and Non-Communicable Diseases in Low- and Middle-Income Countries, with a Focus on Stroke and Dementia. Int J Environ Res Public Health. 2019;16(18). Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet. 2017;389(10072):951–63. Segoviano-Mendoza M, Cárdenas-de la Cruz M, Salas-Pacheco J, Vázquez-Alaniz F, La Llave-León O, Castellanos-Juárez F, et al. Hypocholesterolemia is an independent risk factor for depression disorder and suicide attempt in Northern Mexican population. BMC Psychiatry. 2018;18(1):7. Bojanić I, Sund ER, Sletvold H, Bjerkeset O. Prevalence trends of depression and anxiety symptoms in adults with cardiovascular diseases and diabetes 1995–2019: The HUNT studies, Norway. BMC Psychol. 2021;9(1):130. Cyranka K, Matejko B, Klupa T, Małecki M, Cyganek K, Kieć-Wilk B, et al. Type 1 Diabetes and COVID-19: the level of anxiety, stress and the general mental health in comparison to healthy control. Psychiatr Pol. 2021;55(3):511–23. Stein DJ, Benjet C, Gureje O, Lund C, Scott KM, Poznyak V, et al. Integrating mental health with other non-communicable diseases. BMJ. 2019;364:l295. Azizpour Y, Ehsani R, Karimi K, Olyaeemanesh A, Delavari A, Vosoogh-Moghaddam A, et al. Developing a pilot study protocol and lessons from Iran for the integrated and repeated public health surveillance system (IRPHS). J Diabetes Metab Disord. 2025;24(2):191. Ahmadi SM, Masjedi Arani A, Bakhtiari M, Emamy M. Psychometric Properties of Persian Version of Patient Health Questionnaires-4 (PHQ-4) in Coronary Heart Disease Patients. Iran J Psychiatry Behav Sci. 2020;13. Mohamadian R, Khazaie H, Ahmadi SM, Fatmizade M, Ghahremani S, Sadeghi H, et al. The Psychometric Properties of the Persian Versions of the Patient Health Questionnaires 9 and 2 as Screening Tools for Detecting Depression among University Students. Int J Prev Med. 2022;13:116. Mohammadian Y, Mahaki B, Lavasani FF, Dehghani M, Vahid MA. The psychometric properties of the Persian version of Interpersonal Sensitivity Measure. J Res Med Sci. 2017;22:10. Verhaak PF, Heijmans MJ, Peters L, Rijken M. Chronic disease and mental disorder. Soc Sci Med. 2005;60(4):789–97. Tareke M, Bayeh AB, Birhanu M, Belete A. Psychological distress among people living with chronic medical illness and the general population, Northwest Ethiopia: A comparative cross-sectional study. PLoS ONE. 2022;17(12):e0278235. Xiao S, Shi L, Dong F, Zheng X, Xue Y, Zhang J, et al. The impact of chronic diseases on psychological distress among the older adults: the mediating and moderating role of activities of daily living and perceived social support. Aging Ment Health. 2022;26(9):1798–804. Santos MA, Ceretta LB, Réus GZ, Abelaira HM, Jornada LK, Schwalm MT, et al. Anxiety disorders are associated with quality of life impairment in patients with insulin-dependent type 2 diabetes: a case-control study. Braz J Psychiatry. 2014;36(4):298–304. Vancampfort D, Koyanagi A, Hallgren M, Probst M, Stubbs B. The relationship between chronic physical conditions, multimorbidity and anxiety in the general population: A global perspective across 42 countries. Gen Hosp Psychiatry. 2017;45:1–6. Sharpe L, Michalowski M, Richmond B, Menzies RE, Shaw J. Fear of progression in chronic illnesses other than cancer: a systematic review and meta-analysis of a transdiagnostic construct. Health Psychol Rev. 2023;17(2):301–20. Hallab A. Mediating effect of pro-inflammatory cytokines in the association between depression, anxiety, and cardiometabolic disorders in an ethnically diverse middle-aged and older population. medRxiv. 2025. Uphoff EP, Newbould L, Walker I, Ashraf N, Chaturvedi S, Kandasamy A, et al. A systematic review and meta-analysis of the prevalence of common mental disorders in people with non-communicable diseases in Bangladesh, India, and Pakistan. J Glob Health. 2019;9(2):020417. Daré LO, Bruand P-E, Gérard D, Marin B, Lameyre V, Boumédiène F, et al. Co-morbidities of mental disorders and chronic physical diseases in developing and emerging countries: a meta-analysis. BMC Public Health. 2019;19(1):304. Mehdi S, Wani SUD, Krishna KL, Kinattingal N, Roohi TF. A review on linking stress, depression, and insulin resistance via low-grade chronic inflammation. Biochem Biophys Rep. 2023;36:101571. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8539851","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":589313629,"identity":"7739ef27-965e-47b4-ad46-114b154f6e47","order_by":0,"name":"Masih Hashemi","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Masih","middleName":"","lastName":"Hashemi","suffix":""},{"id":589313633,"identity":"e7aac6df-36b6-4ba1-b5b8-51a974a909be","order_by":1,"name":"Pardis Zarepour","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Pardis","middleName":"","lastName":"Zarepour","suffix":""},{"id":589313636,"identity":"909d8cec-3ab9-41ed-93b4-a087af8c569b","order_by":2,"name":"Sarmad Salehi","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Sarmad","middleName":"","lastName":"Salehi","suffix":""},{"id":589313638,"identity":"0e094561-9dbf-4090-a238-bf503011d16b","order_by":3,"name":"Yosra Azizpour","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Yosra","middleName":"","lastName":"Azizpour","suffix":""},{"id":589313639,"identity":"b04e004d-414d-4c8c-b0b0-d669e27dfd3d","order_by":4,"name":"Samaneh Akbarpour","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Samaneh","middleName":"","lastName":"Akbarpour","suffix":""},{"id":589313641,"identity":"c71ad17e-8c83-45e6-94b0-043e2ee47682","order_by":5,"name":"Mohanna khojaste","email":"data:image/png;base64,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","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Mohanna","middleName":"","lastName":"khojaste","suffix":""}],"badges":[],"createdAt":"2026-01-07 10:08:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8539851/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8539851/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104721981,"identity":"bec33894-865e-4a69-9f21-cd931de42786","added_by":"auto","created_at":"2026-03-16 12:29:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1237487,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8539851/v1/074f615a-1a9d-4c72-8301-d1c6246191e5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anxiety, depression, and suicidal ideation among patients with non-communicable diseases versus the general population in Southern Tehran: a cross-sectional study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAccording to WHO, Non-communicable diseases (NCDs) account for 41\u0026nbsp;million deaths, which is equal to 71% of deaths around the world (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) .Since the Industrial Revolution, NCDs have had the greatest disease burden, and in 2021, NCDs accounted for 1.73\u0026nbsp;billion disability-adjusted life years (DALYs) worldwide (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This situation is also reflected in Iran. NCDs account for 83.5% of all deaths and 78.1% of the burden of diseases in Iran (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The loss of functionality in NCD patients occurs in different secondary conditions (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In addition to these secondary conditions, mental health outcomes have also affected the quality of life of many NCD patients (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere have been some studies on the association between NCDs and mental health outcomes. For example, a study revealed that the risk of suicide attempt was 5.54 times higher among patients with hypercholesterolemia compared to the general population (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Also studies confirm a higher prevalence of depression among cardiovascular diseases (CVD) patients compared to non-patients and Anxiety and stress levels are higher in individuals with type 2 diabetes than in the general population (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Although this association is somewhat accepted among clinicians, further studies are needed to be conducted for more information on this correlation (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is a little information about this association in the Iranian population. The aim of this study is to estimate the prevalence of mental health outcomes including depression, anxiety, and suicidal ideation, among individuals with four major NCDs \u0026ndash; hypertension (HTN), CVD, dyslipidemia and diabetes \u0026ndash; using data from a survey conducted in the general population of southern Tehran. Studies such as this research can be helpful to healthcare policymakers, so that they can prevent the further negative impacts of these mental disorders.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was based on a secondary analysis of data from a telephone-based survey conducted in the southern region of Tehran between May 22 and September 24, 2023, in three strata of southern Tehran province: South Tehran, Rey, and Eslamshahr. The Survey employed a stratified random sampling design with probability proportional to size (PPS) to achieve population representativeness. Sampling frames were constructed from landline telephone registers, and within each contacted household, one eligible adult was randomly chosen for an interview (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The initial survey included 1,311 adults aged 18 years and older.\u003c/p\u003e \u003cp\u003eFor this secondary analysis focusing on NCDs, the sample was restricted to participants aged 25 years or older, leading to the exclusion of 135 individuals under the age of 25. Further exclusions were applied for a history of cancer (n\u0026thinsp;=\u0026thinsp;7) and missing data on mental health outcomes (n\u0026thinsp;=\u0026thinsp;28), wealth index (n\u0026thinsp;=\u0026thinsp;8), insurance status (n\u0026thinsp;=\u0026thinsp;7), and employment status (n\u0026thinsp;=\u0026thinsp;2). This process yielded a final analytic sample of 1,124 individuals.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection and Measurements\u003c/h3\u003e\n\u003cp\u003eData used in this study were collected by trained interviewers. The Questionnaire\u0026rsquo;s validity was checked by public healthcare experts for simplicity and clarity. To further check the content validity of the checklist, content validity ratio (CVR) and content validity index (CVI) were measured. After receiving the CVR and CVI of items in the questionnaire, it was readjusted so that all items have reached the accepted level(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eNCDs\u003c/h3\u003e\n\u003cp\u003eNCDs analyzed in this study were HTN, CVD, dyslipidemia, and diabetes. Each of these diseases was assessed based on the question: \"Has a doctor or healthcare provider ever told you that you have this condition?\" Participants who answered \"yes\" to having any of these diseases were classified into the NCD group.\u003c/p\u003e\n\u003ch3\u003eMental Health Outcomes\u003c/h3\u003e\n\u003cp\u003eThis research studied three mental health outcomes\u0026mdash;anxiety, depression, and suicidal ideation\u0026mdash;which were assessed using six questions. Anxiety and depression were measured by validated and adjusted tools like Generalized anxiety disorder (GAD-2) and the Patient Health Questionnaire-2 (PHQ-2) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Each mental health outcome was assessed using two questions on a four-point scale. The responses were scored and summed to create a composite score for each condition: 0\u0026thinsp;=\u0026thinsp;Not at all, 1\u0026thinsp;=\u0026thinsp;several days, 2\u0026thinsp;=\u0026thinsp;More than half the days, 3\u0026thinsp;=\u0026thinsp;nearly every day. For suicidal ideation, 2 questions (questions 23 and 25) from General Health Questionnaire (GHQ 28) were used and scores were given based on the answers from the respondent. The questions were \u0026ldquo;In the last month, have you felt that life is completely hopeless\u0026rdquo; and \u0026ldquo;In the past month, have you considered whether you want to end your life?\u0026rdquo;\u003c/p\u003e \u003cp\u003eMental distress was operationalized both as a composite outcome and as separate subdomains. The composite mental distress score was created by summing three variables: depression, anxiety, and suicidal ideation. Each subdomain (depression, anxiety, and suicidal ideation) was also analyzed separately as an outcome. The continuous scores for depression, anxiety, and mental distress were converted into ordinal variables with three levels (\"Low,\" \"Moderate,\" \"High\") using tertile splits. Suicidal ideation was binary-categorized as either \"Low\" or \"High\u0026rdquo;.\u003c/p\u003e\n\u003ch3\u003eSociodemographic factors\u003c/h3\u003e\n\u003cp\u003eThe sociodemographic factors analysed in this study were age (\u0026lt;\u0026thinsp;60, 60\u0026ge;), sex (Male or Female), area of residence (Urban or Rural), insurance (with or without health insurance), socioeconomic status (Low, Middle or High), marital status (single, married, divorce/widow), Employment status (Unemployed, employed and Retired), Education level(Illiterate and elementary, Under Diploma, Diploma and Collegiate) and whether the respondents received medical services from public healthcare centers in the last year or not.\u003c/p\u003e \u003cp\u003eSocioeconomic status was assessed using the question: \u0026ldquo;Which of the 5 socioeconomic classes, if the whole Iranian population were divided into them, would your family be in\u0026rdquo; Respondents selected one of five options: high, above average, average, below average, or low. Based on these responses, participants were classified into three categories: low (low and below average), middle (average), and high (high and above average).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe characteristics of the study were summarized using descriptive statistics. For categorical variables, we report proportions (percentages) and 95% confidence intervals.\u003c/p\u003e \u003cp\u003eMental distress and its subdomains were considered as dependent variables (outcomes), while non-communicable disease (NCD) status was treated as the main independent variable (exposure). Binary logistic regression was applied for dichotomous outcomes, including suicidal ideation. Multinomial logistic regression was used for outcomes with more than two categories, including stress, depression, and overall mental health outcome. For the adjusted model, variables were selected using backward selection approach with a retention criterion of P\u0026thinsp;\u0026lt;\u0026thinsp;0.20. All statistical analyses were performed using STATA software (version 17). The dataset was weighted in accordance with the age and sex composition of Tehran\u0026rsquo;s population, as documented in the 2016 Iranian census, to enhance the representativeness of the sample of Tehran. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 1124 participants were identified. The mean age of the study population was 43.47 years\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49 (95% CI\u0026thinsp;=\u0026thinsp;42.41\u0026ndash;44.32), and 51% (95% CI\u0026thinsp;=\u0026thinsp;47.78\u0026ndash;54.13) were male. Overall, 22% (95% CI\u0026thinsp;=\u0026thinsp;19.05\u0026ndash;24.46) of respondents had one or more NCDs. NCDs include Diabetes (n\u0026thinsp;=\u0026thinsp;80), CVD (n\u0026thinsp;=\u0026thinsp;40), HTN (n\u0026thinsp;=\u0026thinsp;107), dyslipidemia (n\u0026thinsp;=\u0026thinsp;97).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts baseline characteristics based on NCDs. around 57.66% (95% CI\u0026thinsp;=\u0026thinsp;50.28\u0026ndash;64.71) of those with NCDs are female, while 46.66% (95% CI\u0026thinsp;=\u0026thinsp;43.12\u0026ndash;50.18) of those without NCDs are female. Regarding Marital status, 2.09% (95% CI\u0026thinsp;=\u0026thinsp;0.76\u0026ndash;5.62) of those with NCD are single, while among participants without NCDs, this number is 10.59% (95% CI\u0026thinsp;=\u0026thinsp;8.51\u0026ndash;13.11). In terms of education, it\u0026rsquo;s seen that among individuals without NCDs, Diploma and Collegiate have the highest percentages, respectively with 33.89% (95% CI\u0026thinsp;=\u0026thinsp;30.65\u0026ndash;037.28) and 31.76% (95% CI\u0026thinsp;=\u0026thinsp;28.52\u0026ndash;35.19) of respondents without NCDs, and for NCD patients these percentages are respectively 21.23% (95% CI\u0026thinsp;=\u0026thinsp;15.93\u0026ndash;27.72) and 17.84% (95% CI\u0026thinsp;=\u0026thinsp;12.87\u0026ndash;24.21). In contrast, we can see that 42.29% (95% CI\u0026thinsp;=\u0026thinsp;35.45\u0026ndash;49.43) of the participants with NCDs are illiterate or have elementary education, while this number is 17.31% (95% CI\u0026thinsp;=\u0026thinsp;14.67\u0026ndash;20.31) in individuals without NCDs. 63.77% (95% CI\u0026thinsp;=\u0026thinsp;56.69\u0026ndash;70.29) of patients with NCD have received medical services from a healthcare center in the last year. In comparison, 46.89% of non-NCD respondents received medical services from a healthcare center during the same period of time.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics based on NCDS (Column)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eNon-communicable diseases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;1124)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (n\u0026thinsp;=\u0026thinsp;899)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes (n\u0026thinsp;=\u0026thinsp;225)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e% (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge group (Years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder 60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.38 (90.10, 94.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.72 (51.50, 65.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e991\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOver 60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.62 (5.83, 9.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.28 (34.41, 48.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.34 (49.82, 56.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.34 (35.29, 49.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e445\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.66 (43.18, 50.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.66 (50.28, 64.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e679\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.59 (8.51, 13.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.09 (0.76, 5.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.72 (82.96, 88.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.50 (71.02, 82.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e965\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced/widow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.69 (2.57, 5.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.41 (15.28, 26.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.37 (38.99, 45.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.56 (49.27, 63.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e607\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.01 (48.45, 55.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.18 (19.37, 32.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e451\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.62 (3.95, 7.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.26 (12.93, 25.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliterate and elementary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.31 (14.67, 20.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.29 (35.45, 49.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e233\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder Diploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.04 (14.51, 19.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.64 (13.91, 24.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e208\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.89 (30.65, 37.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.23 (15.93, 27.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e371\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollegiate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.76 (28.52, 35.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.84 (12.87, 24.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.47 (4.42, 6.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.86 (3.13, 7.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94.53 (93.25, 95.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.14 (92.53, 96.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocio-economic status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.47 (55.94, 62.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.75 (53.62, 67.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e649\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.69 (32.40, 39.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.33 (28.83, 42.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e425\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.84 (3.43, 6.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.91 (2.03, 7.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBasic insurance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.65 (20.66, 26.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.30 (10.92, 21.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e233\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.35 (73.08, 79.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.70 (78.98, 89.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e891\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRefer to healthcare center in the past year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.89 (43.34, 50.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.77 (56.69, 70.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e544\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.11 (49.53, 56.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.23 (29.71, 43.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e580\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePercentages are column-wise\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the mean scores of mental health outcomes and the prevalence of mental distress, comparing participants with and without NCDs. The mean mental distress score in participants with NCDs is reported as 3.60 (95% CI\u0026thinsp;=\u0026thinsp;3.06\u0026ndash;4.15) while this score is 2.60 (95%CI\u0026thinsp;=\u0026thinsp;2.40\u0026ndash;2.80) among respondents without any NCD, these difference are statically significant (p value\u0026thinsp;=\u0026thinsp;0.001). Additionally, the mean of depression score was 1.03 (95% CI\u0026thinsp;=\u0026thinsp;0.94\u0026ndash;1.12) among individuals without NCDs. in comparison, this score was 1.49 (95% CI\u0026thinsp;=\u0026thinsp;1.24\u0026ndash;1.74) among NCD patients and these differences are statically significant (p value\u0026thinsp;=\u0026thinsp;0.001). In anxiety, 9.11% (95%CI\u0026thinsp;=\u0026thinsp;7.33\u0026ndash;11.26) of individuals without NCDs experience high levels of anxiety and among the individuals with NCDs, this percentage is 15.14% (95% CI\u0026thinsp;=\u0026thinsp;10.79\u0026ndash;20.84). High levels of suicidal ideation were seen in 11.7% (95% CI\u0026thinsp;=\u0026thinsp;9.62\u0026ndash;14.16) of individuals without NCDs while 17.61% (95% CI\u0026thinsp;=\u0026thinsp;13.13\u0026ndash;23.20) of participants with NCD experienced this level of suicidal ideation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence of Mental distress mood based on having at list one of the NCDS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNCDS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental distress Score: mean (\u003c/b\u003e95%CI\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.60 (2.40, 2.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.60 (3.06, 4.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepressive mood score: mean (\u003c/b\u003e95%CI\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.03 (0.94, 1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.49 (1.24, 1.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnxious mood score: mean (\u003c/b\u003e95%CI\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.32 (1.23, 1.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.71 (1.47, 1.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSuicide thoughts mean (\u003c/b\u003e95%CI\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.25 (0.19, 0.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.40 (0.24, 0.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAnxiety % (95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.53 (56.00, 62.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.93 (38.93, 53.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eModerate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.36 (28.17, 34.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.92 (32.28, 46.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.11 (7.33, 11.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.14 (10.79, 20.84)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eDepression % (95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.02 (44.47, 51.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.03 (31.36, 45.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eModerate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.58 (42.04, 49.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.48 (40.47, 54.60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.40 (4.91, 8.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.48 (10.16, 20.23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSuicidal ideation % (95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.30 (85.84, 90.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.39 (76.80, 86.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.70 (9.62, 14.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.61 (13.13, 23.20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eMental distress % (95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.02 (39.52, 46.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.95 (24.72, 37.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eModerate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.35 (39.85, 46.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.07 (40.05, 54.20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.63 (11.40, 16.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.98 (16.79, 28.24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eCI: Confidence interval\u003c/p\u003e \u003cp\u003eNCDs: Non-communicable diseases\u003c/p\u003e \u003cp\u003eStatically significant p values are bolded.\u003c/p\u003e \u003cp\u003ePercentages are column-wise.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows logistic regression analysis for the association between NCDs status and mental distress as an outcome. Patients with NCDs had 2.97 times odds of experiencing high levels of depression compared to low levels than those without NCDs (AOR\u0026thinsp;=\u0026thinsp;2.97, 95% CI\u0026thinsp;=\u0026thinsp;1.68\u0026ndash;5.26).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic Regression Analysis for the Relation between NCDs Status and Mental disorder (as an outcome)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eSuicidal ideation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e1.97 (1.22, 3.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepression\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModerate vs. Low\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003eHigh vs. Low\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAOR (95%CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAOR (95%CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.61 (1.07, 2.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.97 (1.68, 5.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnxiety\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModerate vs. Low\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003eHigh vs. Low\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAOR (95%CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAOR (95%CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.35 (0.92, 1.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.32 (1.40, 3.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental distress\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModerate vs. Low\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003eHigh vs. Low\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAOR (95%CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAOR (95%CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.68 (1.09, 2.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.020\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.47 (1.47, 4.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eAOR: Adjusted for: Age, Sex, Marriage status, Residence, Wealth index, Insurance, Refer to healthcare center, Job, Education\u003c/p\u003e \u003cp\u003eStatically significant p values are bolded.\u003c/p\u003e \u003cp\u003eCI: Confidence interval\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSimilarly, individuals with NCDs have 132% higher odds of experiencing high levels of anxiety compared to those without NCDs (AOR\u0026thinsp;=\u0026thinsp;2.32, 95% CI\u0026thinsp;=\u0026thinsp;1.40\u0026ndash;3.85). Consistently, the odds of reporting high versus low levels of mental distress are also higher in the NCD group (AOR\u0026thinsp;=\u0026thinsp;2.47, 95% CI\u0026thinsp;=\u0026thinsp;1.47\u0026ndash;4.13) compared to the group without NCDs.\u003c/p\u003e \u003cp\u003eLinear regression analysis for association between NCDs status and mental distress showed in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The mental distress score is, on average, 0.97 units higher among patients with NCDs compared to those without NCDs (adjusted β\u0026thinsp;=\u0026thinsp;0.97, 95% CI\u0026thinsp;=\u0026thinsp;0.44\u0026ndash;1.50). The depression score of patients with NCDs is, on average, 0.44 units higher than that of their non-NCD counterparts (Aβ\u0026thinsp;=\u0026thinsp;0.44, 95% CI\u0026thinsp;=\u0026thinsp;0.18\u0026ndash;0.70). For suicidal ideation, the mean score among individuals with NCDs is 0.19 units higher compared to participants without NCDs (Aβ\u0026thinsp;=\u0026thinsp;0.19, 95% CI\u0026thinsp;=\u0026thinsp;0.03\u0026ndash;0.36).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003elinear Regression Analysis for the Relation Between NCDs Status and Mental distress (as an outcome)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eModel 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eModel 3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eβ (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAβ (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAβ (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental distress score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.00 (0.42, 1.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.99 (0.42, 1.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.97 (0.44, 1.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepressive mood score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.46 (0.19, 0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.44 (0.18, 0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.44 (0.18, 0.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnxious mod score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.38 (0.14, 0.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.34 (0.08, 0.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.36 (0.12, 0.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSuicide thoughts score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.15 (-0.2, 0.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.21 (0.04, 0.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.19 (0.03, 0.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eModel 1: Crude\u003c/p\u003e \u003cp\u003eModel 2: Adjusted for age, sex\u003c/p\u003e \u003cp\u003eModel 3: Adjusted for: Age, Sex, Marriage status, Residence, Wealth index, Refer to healthcare center, Job, Education\u003c/p\u003e \u003cp\u003eStatically significant p values are bolded.\u003c/p\u003e \u003cp\u003eCI: Confidence interval\u003c/p\u003e \u003cp\u003eA-beta (Aβ): Adjusted beta coefficient\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings indicate that, on average, individuals with NCDs experience higher levels of mental distress and anxiety compared to those without NCDs. Depression was also more prevalent in this group. These findings point to an association between the presence of NCDs and poorer mental health outcomes.\u003c/p\u003e \u003cp\u003eAs mentioned above, mental distress emerges in higher levels in NCD patients. Our data showed a 1-unit increase in mental distress score of NCD patients compared to those without NCDs. This increase in mental distress score is consistent with other studies, as one study in the Netherland that was conducted on 1,788 chronically medical ill Dutch patients, concluded that chronically patients with illnesses have more mental distress than the normal population as they scored higher on the GHQ questionnaire by around 1 unit (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Another study in northern Ethiopia region showed that the prevalence of mental distress is nearly double in NCD patients (62.0% vs 35.1%) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Increased mental distress can be a result of functional limitation and reduced daily activity in NCD patients, impairment of mobility and social participation leads for frustration and also mental distress. NCDs might also reduce the social support of the patient, which can worsen the mental distress (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, a significant association was found between NCDs and anxiety, with the prevalence being 6% higher among individuals with NCDs compared to those without NCDs (15.14% vs. 9.11%).This means that anxiety is more visible in NCD patients compared to the general population. This finding is supported by other studies, for example, a case-control study of 996 type 2 diabetes patients and 2,145 individuals without diabetes in Brazil, found that 34.1% of patients had generalized anxiety disorder in comparison to 21.8% of general population, showing an increased prevalence of depression in diabetes patient (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Another cross-sectional study conducted across 42 countries, also found that having one chronic condition increases the risk of showing anxiety symptoms by around 100% with an OR of 1.94 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The reason for this anxiety has been discussed in psychological and physiological ways. One psychological mechanism is that the fear of the NCD\u0026rsquo;s progression or even their worsening might cause the anxiety in these patients (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The physiological theory for this contribution is about inflammatory responses that are common in different NCDs as Interleukin-6 (IL-6) has been seen to have a mediating role in anxiety (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt can also be concluded from this study, that depression is more frequently in NCD patients since the odds of depression are 3 times higher in them (AOR\u0026thinsp;=\u0026thinsp;2.97). A systematic review and meta-analysis of 83 studies in South Asia reported high pooled prevalence rates of depression among patients with diabetes (40%), stroke (39%), and hypertension (38%), alongside a pooled anxiety prevalence of 29% (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). another meta-analysis of 40 studies found a pooled odds ratio of 3.1 for depression and anxiety among individuals with chronic diseases, including diabetes, obesity, cancer, chronic obstructive pulmonary disease (COPD), and heart disease (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). There are many suggested explanations for this association. One proposed mechanism for this association involves insulin resistance. This theory posits that impaired insulin signaling can lead to neuroinflammation, which in turn damages neurons and alters brain function to induce depressive symptoms. For instance, pro-inflammatory cytokines, which are elevated due to disrupted glucose metabolism, can lead to reduced serotonin levels (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImplications for Public Health\u003c/p\u003e \u003cp\u003eThe association suggested by this article and similar ones can be implicated in clinical and public health levels. Clinicians can consider routine mental health screening for their NCD patients to minimize the impact of the mental health outcomes on their life quality. In the public health level, a high burden of disease can be resulted by the mental health outcome, setting aside the burden caused by the NCD itself. Future studies on this matter can be focused on finding a physiological mechanism for this association in cellular and systemic levels, or suggested medical treatments to stop or control these outcomes in order to lessen the burden caused by them. A public health approach to this finding can be providing the facility for mental health screening in general hospitals to limit the burden caused by these mental health outcomes.\u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eThe strengths of this study include a relatively large sample size and a representative population. The limitations of this study were the self-reported status of our data and the nature of cross-sectional studies that restricts casual interference.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study show that people living with major non-communicable diseases face noticeably greater emotional and psychological strain than those without such conditions. Higher levels of anxiety, depressive symptoms, suicidal thoughts, and overall mental distress were all more common in the NCD group. These results point to an important gap in current care: routine mental health assessment and support should be incorporated into NCD management programs in Iran to help reduce the added burden these conditions create.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNCD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-communicable disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eGAD-2\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneralized Anxiety Disorder-2\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePHQ-2\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient Health Questionnaire-2\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eGHQ-28\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral Health Questionnaire-28\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAOR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdjusted odds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eA-beta (Aβ)\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdjusted beta coefficient\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWHO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDALYs\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDisability-adjusted life years\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCVD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCardiovascular disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePPS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProbability proportional to size\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCVR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContent validity ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCVI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContent validity index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHTN\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSTATA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eData analysis and statistical software\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCOPD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChronic obstructive pulmonary disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the ethics committee of Tehran university of Medical Sciences, Tehran, Iran (NO. IR.TUMS.MEDICINE.REC.1400.599).As the survey was conducted by telephone, verbal informed consent was obtained from participants before data collection. Participants were informed of the study aims, assured of data confidentiality, advised of voluntary participation and their right to skip any question, and informed about the approximate length of the interview.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors extend their gratitude to the Deputy of Health at Tehran University of Medical Sciences (TUMS) for their partnership. During the preparation of this manuscript, the authors used OpenAI\u0026apos;s ChatGPT and DeepSeek AI to assist with language editing, which improved the clarity and coherence of the text.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.A. conceptualization; P.Z. methodology, formal analysis, and data curation; M.H. writing - original draft; S.S., Y.A., and M.K. writing - review and editing; Y.A. project administration; M.K. supervision.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. Noncommunicable diseases 2025 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi J, Pandian V, Davidson PM, Song Y, Chen N, Fong DYT. Burden and attributable risk factors of non-communicable diseases and subtypes in 204 countries and territories, 1990\u0026ndash;2021: a systematic analysis for the global burden of disease study 2021. Int J Surg. 2025;111(3):2385\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahimi E, Mohammadi R, Mokhayeri Y, Nazari SS. Gender disparity and risk of noncommunicable disease among adults in Islamic Republic of Iran. East Mediterr Health J. 2023;29(8):630\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrynn JE, Kuper H. Perspectives on Disability and Non-Communicable Diseases in Low- and Middle-Income Countries, with a Focus on Stroke and Dementia. Int J Environ Res Public Health. 2019;16(18).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet. 2017;389(10072):951\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSegoviano-Mendoza M, C\u0026aacute;rdenas-de la Cruz M, Salas-Pacheco J, V\u0026aacute;zquez-Alaniz F, La Llave-Le\u0026oacute;n O, Castellanos-Ju\u0026aacute;rez F, et al. Hypocholesterolemia is an independent risk factor for depression disorder and suicide attempt in Northern Mexican population. BMC Psychiatry. 2018;18(1):7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBojanić I, Sund ER, Sletvold H, Bjerkeset O. Prevalence trends of depression and anxiety symptoms in adults with cardiovascular diseases and diabetes 1995\u0026ndash;2019: The HUNT studies, Norway. BMC Psychol. 2021;9(1):130.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCyranka K, Matejko B, Klupa T, Małecki M, Cyganek K, Kieć-Wilk B, et al. Type 1 Diabetes and COVID-19: the level of anxiety, stress and the general mental health in comparison to healthy control. Psychiatr Pol. 2021;55(3):511\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStein DJ, Benjet C, Gureje O, Lund C, Scott KM, Poznyak V, et al. Integrating mental health with other non-communicable diseases. BMJ. 2019;364:l295.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAzizpour Y, Ehsani R, Karimi K, Olyaeemanesh A, Delavari A, Vosoogh-Moghaddam A, et al. Developing a pilot study protocol and lessons from Iran for the integrated and repeated public health surveillance system (IRPHS). J Diabetes Metab Disord. 2025;24(2):191.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmadi SM, Masjedi Arani A, Bakhtiari M, Emamy M. Psychometric Properties of Persian Version of Patient Health Questionnaires-4 (PHQ-4) in Coronary Heart Disease Patients. Iran J Psychiatry Behav Sci. 2020;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohamadian R, Khazaie H, Ahmadi SM, Fatmizade M, Ghahremani S, Sadeghi H, et al. The Psychometric Properties of the Persian Versions of the Patient Health Questionnaires 9 and 2 as Screening Tools for Detecting Depression among University Students. Int J Prev Med. 2022;13:116.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohammadian Y, Mahaki B, Lavasani FF, Dehghani M, Vahid MA. The psychometric properties of the Persian version of Interpersonal Sensitivity Measure. J Res Med Sci. 2017;22:10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerhaak PF, Heijmans MJ, Peters L, Rijken M. Chronic disease and mental disorder. Soc Sci Med. 2005;60(4):789\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTareke M, Bayeh AB, Birhanu M, Belete A. Psychological distress among people living with chronic medical illness and the general population, Northwest Ethiopia: A comparative cross-sectional study. PLoS ONE. 2022;17(12):e0278235.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiao S, Shi L, Dong F, Zheng X, Xue Y, Zhang J, et al. The impact of chronic diseases on psychological distress among the older adults: the mediating and moderating role of activities of daily living and perceived social support. Aging Ment Health. 2022;26(9):1798\u0026ndash;804.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSantos MA, Ceretta LB, R\u0026eacute;us GZ, Abelaira HM, Jornada LK, Schwalm MT, et al. Anxiety disorders are associated with quality of life impairment in patients with insulin-dependent type 2 diabetes: a case-control study. Braz J Psychiatry. 2014;36(4):298\u0026ndash;304.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVancampfort D, Koyanagi A, Hallgren M, Probst M, Stubbs B. The relationship between chronic physical conditions, multimorbidity and anxiety in the general population: A global perspective across 42 countries. Gen Hosp Psychiatry. 2017;45:1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharpe L, Michalowski M, Richmond B, Menzies RE, Shaw J. Fear of progression in chronic illnesses other than cancer: a systematic review and meta-analysis of a transdiagnostic construct. Health Psychol Rev. 2023;17(2):301\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHallab A. Mediating effect of pro-inflammatory cytokines in the association between depression, anxiety, and cardiometabolic disorders in an ethnically diverse middle-aged and older population. medRxiv. 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUphoff EP, Newbould L, Walker I, Ashraf N, Chaturvedi S, Kandasamy A, et al. A systematic review and meta-analysis of the prevalence of common mental disorders in people with non-communicable diseases in Bangladesh, India, and Pakistan. J Glob Health. 2019;9(2):020417.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDar\u0026eacute; LO, Bruand P-E, G\u0026eacute;rard D, Marin B, Lameyre V, Boum\u0026eacute;di\u0026egrave;ne F, et al. Co-morbidities of mental disorders and chronic physical diseases in developing and emerging countries: a meta-analysis. BMC Public Health. 2019;19(1):304.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMehdi S, Wani SUD, Krishna KL, Kinattingal N, Roohi TF. A review on linking stress, depression, and insulin resistance via low-grade chronic inflammation. Biochem Biophys Rep. 2023;36:101571.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Non-communicable diseases, mental health, Depression, Anxiety, Suicidal ideation, mental distress","lastPublishedDoi":"10.21203/rs.3.rs-8539851/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8539851/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eNon-communicable diseases are a major cause of illness and death globally, including in Iran. Although associations with mental health have been suggested, evidence from Iran is limited. This study compared 3 mental health outcomes in adults with and without NCDs in southern Tehran.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis cross-sectional study used secondary data from a telephone-based health survey conducted in southern Tehran (May\u0026ndash;September 2023). Adults aged\u0026thinsp;\u0026ge;\u0026thinsp;25 years were included, yielding a final weighted sample of 1,124 participants. NCD status (hypertension, cardiovascular diseases, dyslipidemia, and diabetes) was self-reported based on prior medical diagnosis. Mental health outcomes (anxiety, depression, suicidal ideation, and overall mental distress) were assessed using validated tools (GAD-2, PHQ-2, GHQ-28 (questions 23 and 25)(. Associations between NCDs and mental health outcomes were examined using multinomial logistic regression and linear regression models, adjusted for sociodemographic and socioeconomic variables.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall, 22% (95% CI\u0026thinsp;=\u0026thinsp;19.05\u0026ndash;24.46) of participants reported at least one NCD. Mental distress scores were significantly higher among individuals with NCDs compared to those without (mean 3.60 (95% CI\u0026thinsp;=\u0026thinsp;3.06\u0026ndash;4.15) vs. 2.60 (95% CI\u0026thinsp;=\u0026thinsp;2.40\u0026ndash;2.80)), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). NCD patients also had higher mean depression (1.49 vs. 1.03, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001) and anxiety scores (1.71 vs. 1.32, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). Suicidal ideation was more prevalent among NCD patients (17.61% vs. 11.70%). Multinomial regression showed that participants with NCDs had increased odds of high depression (Adjusted Odds Ratio [AOR]\u0026thinsp;=\u0026thinsp;2.97, 95% CI\u0026thinsp;=\u0026thinsp;1.68\u0026ndash;5.26), high anxiety (AOR\u0026thinsp;=\u0026thinsp;2.32, 95% CI\u0026thinsp;=\u0026thinsp;1.40\u0026ndash;3.85), and high overall mental distress (AOR\u0026thinsp;=\u0026thinsp;2.47, 95% CI\u0026thinsp;=\u0026thinsp;1.47\u0026ndash;4.13) compared to participants without NCDs. Linear regression showed significantly increased scores for overall mental distress (Adjusted β\u0026thinsp;=\u0026thinsp;0.97, 95% CI\u0026thinsp;=\u0026thinsp;0.44\u0026ndash;1.50), depression (Aβ\u0026thinsp;=\u0026thinsp;0.44, 95% CI\u0026thinsp;=\u0026thinsp;0.18\u0026ndash;0.70), anxiety (Aβ\u0026thinsp;=\u0026thinsp;0.36,95% CI\u0026thinsp;=\u0026thinsp;0.12\u0026ndash;0.60), and suicidal ideation (Aβ\u0026thinsp;=\u0026thinsp;0.19, 95% CI\u0026thinsp;=\u0026thinsp;0.03\u0026ndash;0.36) among NCD patients.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAdults living with NCDs show markedly higher levels of mental distress than those without these conditions, underscoring the importance of incorporating routine mental health assessment and support into NCD care in Iran.\u003c/p\u003e","manuscriptTitle":"Anxiety, depression, and suicidal ideation among patients with non-communicable diseases versus the general population in Southern Tehran: a cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-12 16:30:05","doi":"10.21203/rs.3.rs-8539851/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2de8dc80-4612-4c9d-8b9c-994d625d9210","owner":[],"postedDate":"February 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T12:27:48+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-12 16:30:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8539851","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8539851","identity":"rs-8539851","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}