Diabetes Risk and Depression Among Adults Without Known Diabetes: A Community-Based Mixed-Methods Study in Rural Puducherry, India

Background: Diabetes and depression are important and interrelated public health concerns.However, evidence on the relationship between diabetes risk and depressive symptoms among adults without known diabetes is limited.This study assessed the association between diabetes risk and depression and explored related perceptions and experiences among adults in rural Puducherry, India.Methods: A sequential explanatory mixed-methods study was conducted among adults without known diabetes in rural Puducherry from January to June 2026.Using multistage random sampling, 376 eligible participants were approached, of whom 336 participated in the study, yielding a response rate of 89.4%.The minimum sample size was 216, calculated using a previously reported depression prevalence of 16.9%, a 95% confidence level, and a 5% absolute precision; after applying a design effect of 1.5, the required sample size was 324.Diabetes risk was assessed using the Indian Diabetes Risk Score (IDRS), and depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9).Chi-squared tests and multivariable logistic regression were used to assess associations.In-depth interviews were conducted with purposively selected participants and were analyzed thematically.Results: The mean age was 50.5 ± 16.4 years, the mean IDRS was 45.45 ± 17.38, and the mean PHQ-9 score was 3.35 ± 4.50.Overall, 87 (25.9%) participants screened positive for depression.IDRS classified 46 (13.7%) as low risk, 255 (75.9%) as moderate risk, and 35 (10.4%) as high risk.The high-risk IDRS group comprised 35 participants; estimates for this subgroup should be interpreted cautiously because of the small sample size.Depression increased across IDRS categories from seven (15.2%) in the low-risk group to 65 (25.5%) in the moderate-risk group and 15 (42.9%) in the high-risk group (χ² = 8.003; p = 0.018).The IDRS category was independently associated with depression after adjustment.Sleep duration and daily fruit and vegetable intake remained significantly associated with depression.Qualitative findings identified perceived diabetes risk, lifestyle barriers, psychosocial stress, coping and social support, and healthcare-seeking experiences.Conclusion: Depression was common among adults without known diabetes, with a higher prevalence observed among those with greater IDRS-defined diabetes risk in the unadjusted analysis.The findings highlight the potential value of integrating mental health assessment with community-based diabetes-risk screening and addressing modifiable lifestyle and psychosocial factors.