https://doi.org/10.15218/ejnm.2023.20 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Psychological Distress in Diabetic and Myocardial Infarction Patients in Erbil City- Comparative Study ABSTRACT Background and Objectives: Psychological distress refers to a range of negative emo- tional experiences, such as anxiety, depression, and stress. Diabetes mellitus and myo- cardial infarction are two medical conditions that can have a significant impact on an individual's psychological well-being. Therefore, the study aimed to assess and compare psychological distress among diabetes mellitus and myocardial infarction patients in Er- bil city. Methods: A quantitative, comparative study design was conducted on 100 patients whom 50 of them were diabetes mellitus patients at Layla Qasim Health Center and the other 50 were myocardial infarction patients at the Cardiac Centre in Erbil city. The data was collected from 20th April 2022 till 24th May 2023. Results: The result showed that less than half of myocardial infarction patients were old adults which is 42% between 57-68 years, married, illiterate and living in urban. On the other hand, less than half of diabetes mellitus patients were middle-aged adults, which is 42% between 45-56 years, married illiterate and living in urban. The ranges of the gen- ders are equal with 50% being male and 50% being female. Also, more than half of myo- cardial infarction patients are non-smokers 52%, and 34% are smokers. In contrast, less than half of diabetes mellitus patients are 40% non- smokers, and 20% are smokers. Conclusions: The majority of diabetic mellitus patients had a moderate level of depres- sion. At the same time, anxiety and stress were extremely severe, and most patients with myocardial infarction had an extremely severe level of depression, anxiety and stress. Keywords: Psychological Distress; Diabetes Mellitus; Myocardial Infarction; Patients. Mosleh Saber Kareem; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: mosleh.kareem@hmu.edu.krd) Muhammad Hasan Awla; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Dlzar Sadeeq Anwar; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Iman Saleh Azeez; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Sideeq Sadir Ali; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 193 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Received: 24/06/2023 Accepted: 19/11/2023 Published: 30/11/2023 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Psychological distress is a common mental health problem in the community. It is a state of emotional suffering typically char- acterized by symptoms of depression, anxi- ety and stress. Patients with chronic diseas- es may experience negative emotions, such as depression. It is an unpleasant or emo- tional feeling that affects the functional capacity of individuals; psychological dis- tress interferes with activities of daily living and easily results in negative views of one's self, others, and the environment around them [1]. Psychological distress is largely defined as a state of emotional suffering characterized by symptoms of depression, stress and anxiety [2]. Stress is a state of mental or emotional strain or tension that results from adverse or demanding circum- stances [3]. Anxiety is the most common, or frequently occurring, mental disorder, which is characterized by restlessness and disturbance of thinking and behavior [4]. Depression is the most common mental health condition in the general population, characterized by sadness, loss of interest or pleasure, disturbed sleep or appetite, feel- ings of tiredness, and poor concentration [5]. Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves. The most common is type 2 diabetes, usually in adults, which occurs when the body be- comes resistant to insulin or doesn't make enough insulin. In the past three decades the prevalence of type 2 diabetes has risen dramatically in countries of all income lev- els [6]. A heart attack, also called a myocar- dial infarction, happens when a part of the heart muscle does not get enough blood. The more time that passes without treat- ment to restore blood flow, the greater the damage to the heart muscle. Coronary ar- tery disease (CAD) is the main cause of heart attacks. A less common cause is a severe spasm, or sudden contraction, of a coronary artery that can stop blood flow to the heart muscle [7].Depression is recog- nized as an independent risk factor for the development of myocardial infarction. The prevalence of psychological distress among MI patients is high, with depression ex- isting in 70.7% of patients and anxiety symptoms (24%) [8]. Also, the prevalence of psychological distress in patients with DM ranges from 18 % to 52 % globally [9]. Myocardial infarction (MI) is a serious and potentially life-threatening disease, that has often been associated with significant anxiety and depression in patients. It caus- es substantial morbidity and mortality [10]. The estimated prevalence of depression in patients with chronic diseases ranges from 9.3 to 25% and patients with chronic dis- eases such as hypertension, coronary heart disease, and diabetes have a high inci- dence of depression. the depression and the cardiovascular risk are strongly corre- lated and many patients with chronic dis- eases have mental disorders, such as de- pression, because of the long-term nature of the disease and its impact on quality of life [11]. Anxiety after a myocardial infarc- tion (MI) is common. Most of the MI pa- tients showed ahigh level of anxiety imme- diately after the diagnosis of the disease both in western and eastern countries, namely; Australia, England, Japan, South Korea, and the United States. Similarly, in a study of the Norwegian population with MI, a higher level of anxiety in the initial phase (20%) was reported [12]. Some stud- ies have reported that patients with diabe- tes are almost twice as likely to suffer from anxiety and depression as the general pop- ulation and between 20% and 40% of peo- ple with T2DM experience feelings of anxi- ety, depression and stress [13]. Around 14% of people with diabetes have diagnos- able general anxiety disorder and up to 194 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Centre in Erbil City. The study was con- ducted from 12th April 2023 to 20th June 2023 and the data was collected from 20th April 2022 to 24th May 2023. The data was collected through a questionnaire that consisted of two parts: Part one: Socio- demographic data (age, gender, marital status, occupational status, religion, living area, economic status, level of education, sleep quality, smoking state and high blood pressure) Part two; Depression, Anxiety and Stress Scale - 21 Items (DASS-21) is a set of three self-report scales designed to measure the emotional states of depres- sion, anxiety and stress. Each of the three DASS-21 scales contains 7 items, divided into subscales with similar content. The rating scale is as follows: (0, 1, 2, and 3): 0 did not apply to me at all. 1 applied to me to some degree, or some of the time. 2 applied to me to a considerable degree or a good part of time. 3 applied to me very much or most of the time. Scales The DASS yields three subscale scores for depression, anxiety, and tension/stress. DASS Anxiety = 2 + 4 + 7 + 9 + 15 + 19 + 20 DASS Depression = 3 + 5 + 10 + 13 + 16 + 17 + 21 DASS Stress = 1 + 6 + 8 + 11 + 12 + 14 +18 Recommended cut-off scores for conven- tional severity labels (normal, moderate, severe) are as follows: Scores on the DASS- 21 will need to be multiplied by 2 to calcu- late the final score [15]. 40% have subsyndromal elevated anxiety levels. An emerging body of literature sug- gests that stress has a role in the etiology of type 2 diabetes mellitus (T2DM) both as a predictor of new-onset T2DM and as a prognostic factor in people with existing T2DM [14].According to the researcher’s expectations in our society, psychological distress affects the immune system and the patient’s health condition and thus leads to chronic diseases, especially diabetes and myocardial infarction. Therefore, research- ers attempted to evaluate psychological distress among patients with diabetes and myocardial infarction in the city of Erbil and identify the main points between pa- tients with diabetes and myocardial infarc- tion. The present study is a quantitative, com- parative study conducted to assess psycho- logical distress (depression, anxiety, and stress) among diabetic and myocardial in- farction patients in Erbil City. The formal arrangement was taken From the College of Nursing / scientific committee, also took permission from Layla Qasim Health Cen- ter, Hawler Teaching Hospital, Rizgary Teaching Hospital and Surgical Specialty Hospital-Cardiac Centre. The sample of the study was estimated at 100 patients from both Diabetes Meletus (DM) and Myocardi- al Infarction (MI) (50 Diabetic and 50 MI patients) in Erbil City, at the same time, 12 patients with DM and 11 patients with MI refused to participate in the present study. Regarding the inclusion criteria, there were diabetic and myocardial infarction patients of both genders and over the age of eight- een years old, while the exclusion criteria were; patients who had cancer or mental problem. The settings of the study were from Layla Qasim Health Center, Hawler Teaching Hospital, Rizgary Teaching Hospi- tal and Surgical Specialty Hospital-Cardiac 195 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article The research followed the most recent ver- sion of the Declaration of Helsinki, and the study received ethics approval from the Human Research Ethics Committee at the Hawler Medical University/ College of Nursing under the code 10. The data was analyzed using the Statistical Package for Social Sciences (SPSS, Version 26), using two statistical analyses: Frequency and percentage descriptive data analysis, and independent samples t-test, mean differ- ence, 95% confidence interval of the differ- ence mean and standard deviation for comparative between both types of dis- ease. For comparative analysis between mean of diabetic and myocardial infarction used a P-value of ≤ 0.05 was considered statistically significant. The demographics of 100 patients with both myocardial infarction and diabetes mellitus are displayed in Table 1. The table also displays divinations among MI and DM patients with varying ages, genders, socio- economic backgrounds, and quality of sleep. The ages of the participants ranged from 33 to 69. Patients aged 57 to 68, they made up the largest age group (42%) of those diagnosed with a myocardial infarc- tion. The next tier, comprising 30% of the total, included those aged 45–56. Ages 69 and up accounted for 26% of those with the third stage of MI. The incidence of MI was lowest in those aged 33- 44 (2%). In contrast, 42% of people with DM fell within the age range of 45-56. Between the ages of 57 and 68 made up the next tier, repre- senting 28%. People aged 69 and up had type 3 diabetes, representing around 16% of the population. The smallest percentage, 14%, came from ages 33 to 44. The mean age and standard deviation in MI were 61.54 ± 9.842 and in DM was 55.60± 10.087. Both males and females made up 50% of the MI and DM patient populations. Participants' marital status varied widely; for example, among those with MI, 90% were married, and 10% were widowed. In contrast, the majority of people with dia- betes were married. In addition, 14% were either widowed. Patients with MI were more likely to live in an urban region (84%) than in a rural area (16%). Moreover, 92% of type 2 diabetes patients were city dwell- ers, whereas only 8% were residents of rural areas. Concern the level of education, of participants were largely illiterate (46%), with only 14% able to read and write. While 22% had completed high school, 8% had completed middle school, and 10% had completed colleges or universities. Pa- tients with diabetes mellitus had the fol- lowing educational attainment levels: (50%) do not know how to read or write, while (6%) do. 24% have only completed elementary school, 18 % have completed middle school, and 2% have completed high school and college). In Table 1. shows that just 28% of the MI participants were actively employed, while 72% were not, and 0% were retired. Cases of DM included people who were either working (14%), not working (76%), or retired (10 %). The table also includes the income of each per- son based on their profession. Most heart attack patients (84%), of them had high incomes (4%), had low incomes, (12%) fell within the middle class. Regarding the eco- nomic status of the study sample, had 2% had a very high income, the majority of them had somehow income, and 30 % were poor in economic statutes. Regarding the participant’s personal health condi- tions, the table also shows some other cri- teria regarding their health. The quality of sleep reported by those with a MI was as follows: Patients were more likely to re- port good sleep quality (64%), fewer sleep problems (18%), and shorter sleep dura- tion (18%). However, just 26% of DM pa- tients reported poor sleep quality, 34% 196 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULTS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 197 shared a common religious background: they were all Muslims. Last but not least, the table details whether or not any par- ticipants suffered from any additional chronic diseases. 54% of MI patients were disease-free, whereas nearly half had hypertension. Asthma affected 2% of the population. Despite this, more than half of the diabetic individuals 64 % were otherwise healthy. Hypertension affected 34% whereas asthma affected only 2%. Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. reported sleeping difficulties, and 64% reported getting enough sleep. This table shows the percentage of smokers and nonsmokers within our patient popula- tion. There were more non-smokers (52%) than smokers (34%), passive smokers (8%) than smokers (34%), and former smokers (6%) among MI patients. While 40% of DM patients were never smokers, 18% were non-smokers, 20% were never active smokers, and 22% were never active ex- smokers. Patients with both MI and DM Table 1: Socio Demographic Characteristics of Study Participants. Socio demographic characteristics Myocardial Infarction Diabetes Mellitus Frequency (n=50) Percentage (%) Frequency Percentage (n=50) (%) Age group (years) 33-44 1 (2) 7 (14) 45-56 15 (30) 21 (42) 57-68 21 (42) 14 (28) >69 13 (26) 8 (16) M ± SD 61.54 ± 9.842 55.60 ± 10.087 Gender Male 25 (50) 25 (50) Female 25 (50) 25 (50) Marital status Single 0 (0) 0 (0) Married 45 (90) 42 (84) Divorce 0 (0) 1 (2) Widowed 5 (10) 7 (14) Residential area Urban 42 (84) 46 (92) Rural 8 (16) 4 (8) Level of education Illiterate 23 (46) 25 (50) Read and write 7 (14) 3 (6) Primary school 11 (22) 12 (24) Secondary school 4 (8) 9 (18) Institute and college 5 (10) 1 (2) Occupational status Employment non-employed 14 36 (28) (72) 7 38 (14) (76) Retirement 0 (0) 5 (10) Economic status High income 2 (4) 1 (2) Middle income 42 (84) 34 (68) Low income 6 (12) 15 (30) Sleep quality Good sleep quality 32 (64) 20 (40) Difficulty sleeping 9 (18) 17 (34) Short sleep 9 (18) 13 (26) Smoking Pattern Non-smoker 26 (52) 20 (40) Passive smoker 4 (8) 9 (18) Smoker 17 (34) 10 (20) Ex-smoker 3 (6) 11 (22) Religion Muslim 50 (100) 50 (100) Other chronic disease Non Hypertension 27 22 (54) (44) 32 17 (64) (34) Asthma 1 (2) 1 (2) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article moderate (4%), normal (6%) and mild (10%)-while (14%) of DM patients had ex- tremely high levels of anxiety. Contrarily, the anxiety levels of MI patients varied widely, with 2 percent of them reporting normal anxiety, 6 percent reporting mild anxiety, 20 percent reporting moderate anxiety, 8 percent reporting severe anxie- ty, and 64 percent reporting the highest levels of anxiety. The levels of stress among DM patients were as follows: 10 % of the patients experienced both normal and moderate levels of stress. Only 2% of them had a severe level of stress; mean- while, more than half (60%) had extremely severe stress. On other hand, the levels of stress among MI patients are also differ- ent; the normal to mild level were 2% and 6%. 20% had moderate stress levels, 24% had a severe level and highest level was extremely severe level of stress among MI patients was 48%. 198 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2 displays the prevalence of depres- sion, anxiety, and stress among individuals with diabetes and myocardial infraction (MI). Five categories-normal, mild, moder- ate, severe, and extremely severe - are used to categorize the severity of depres- sion. Less than half of the study sample had diabetes mellitus and 34% had moderate levels of depression. The lowest level of depression was 14% and it showed both mild and severe symptoms, while 16% of them had a normal level of depression. Among the patients, 22% had an extremely severe depression. The levels of depression among MI patients were as follows: 8 % of them had a normal and mild depression, 30 % had a moderate level of depression, 6 % had severe level, and 48 % had an extreme- ly severe level, which was the highest per- centage among them. In Table 2, the levels of anxiety were also displayed. Most DM patients (66%), who had extremely high levels of anxiety , had the lowest levels— Table 2: Depression, Anxiety and Stress Level Among Diabetic and Myocardial Infarction Patients Frequency (n=50) Percentage (%) Frequency (n=50) Percentage (%) Level of Depression Normal Mild 8 7 (16) (14) 4 4 (8) (8) Moderate 17 (34) 15 (30) Severe 7 (14) 3 (6) Extremely Severe 11 (22) 24 (48) Level of anxiety Normal 3 (6) 1 (2) Mild 5 (10) 3 (6) Moderate 2 (4) 10 (20) Severe 7 (14) 4 (8) Extremely Severe 33 (66) 32 (64) Level of stress Normal 7 (14) 3 (6) Mild 5 (10) 1 (2) Moderate 7 (14) 10 (20) Severe 1 (2) 12 (24) Extremely Severe 30 (60) 24 (48) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article anxiety among MI patients, which are 10.56, while the deviation is 9.163, the confidence of the interval of the difference lower is -0.404 and higher is 4.804 as the p value is 0.096. Additionally, the results of overall stress levels among DM patients are 18.20, and total stress levels among MI patients are 16.92, as shown in the table. Also, the deviation is 11.305, the lower confidence interval for the difference is - 1.933, and the higher confidence interval is 4.493, with a p value of 0.425. myocardial infarction patients, and both of these investigations revealed that the pa- tients had poor or insufficient sleep [17]. In Table 2, depression, anxiety, and stress levels were listed for diabetic and myocar- dial infarction patients. The majority of di- abetic patients had moderate levels of de- pression, which was inconsistent with a quantitative cross-sectional study about the relationship between depression, anxi- ety, and stress symptoms and glycemic control in diabetes mellitus patients, which found that most patients were suffering. A study revealed the high prevalence of de- pression among MI patients [8]. Supports the finding that the majority of patients with this condition had highly severe levels Table 3 compares the averages for diabe- tes and myocardial infraction and displays the overall levels of stress, anxiety, and depression. The average level of depres- sion in DM patients is 10.28, while the av- erage level of depression in MI patients is 13.52, with a standard deviation of 9.755. and the lower and upper limits of the con- fidence interval for the difference are - 6.012 and -0.468, respectively, while the p value is 0.023, which means that statisti- cally was significant. Regarding the total levels of anxiety among DM patients, which are 12.76, and the total levels of In this study, psychological discomfort is compared between diabetic and myocar- dial infarction patients in Erbil City. The majority of the patients were between the ages of forty-five and fifty-six in the first part of the age group distribution. This re- sult was in agreement with a case-control study about the high prevalence of de- pressive, anxious, and stress symptoms among diabetes mellitus patients, which revealed that the majority of patients fell within these age ranges [13].The majority of patients reported having good sleep quality, but two studies contradicted one study's findings among type 2 diabetes patients in the United States [16]. Another study looked at sleep disturbances in 199 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 3: Comparative between Mean of Diabetic and Myocardial Infarction Total level of DASS Mean Std. Deviation 95% Confidence Interval of the Difference t-value P-value Lower Upper Depression - DM 10.28 9.755 -6.012 -0.468 -2.348 0.023 Depression-MI 13.52 Anxiety – DM 12.76 9.163 -0.404 4.804 1.698 0.096 Anxiety-MI 10.56 Stress – DM 18.20 11.305 -1.933 4.493 0.801 0.427 Stress-MI 16.92 DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article The majority of diabetic mellitus patients were had a moderate level of depression, while anxiety and stress were extremely severe, the majority of patients who had myocardial infarction had an extremely severe level of depression, anxiety and stress. About the comparative level of psy- chological distress among Diabetic Mellitus (DM) and Myocardial Infarction (MI) pa- tients, the results showed a difference be- tween them in that the DM level of de- pression was lower than that of MI, but the level of stress and anxiety in DM was higher than that of MI patients. [1] Doglikuu BD, Abdulai A, Yaseri M, Shakibaza- deh E, Djazayery A and Mirzae K. Do Interac- tions Between Patients’ Psychological Dis- tress and Adherence to Dietary Recommen- dation Predict Glycemic Control Among Per- sons with Type2 Diabetes in Ghana. Life style medicine article. 2021; 1(1): 4-2. doi:10.1002/lim2.22 [2] Drapeau A, Marchand A, Prevost DB. Epide- miology of Psychological Distress. Mental Illnesses Understanding Prediction and Con- trol.2012; 5 (2): 105-6. doi: 10.5772/30872 [3] Surwit RS, Schneider MS, Feinglos MN. Stress and Diabetes Mellitus. Diabetes care journal. 1992; 15 (10): 1413-22. doi.org/10.2337/diacare.15.10.1413 [4] Adwas AA, Jbireal JM, Azab AE. Anxiety: In- sights into Signs, Symptom, Etiology, Patho- physiology and Treatment. East African Scholars Journal of Medical Sciences. 2019; Volume 2, Issue10. www.easpublisher.com [5] Lim GY, Tam WW, Lu Y, Ho CS, Zhang MW. Prevalence of Depression in the Community from 30 Countries between 1994 and 2014. Scientific Reports Journal.2018; 8:2861. doi:10.1038/s41598-018-21243-x [6] World Health Organization. Diabetes Melli- tus. 2023. https://www.who.int/ [7] Centers for Disease Control and Prevention. Hart attacks symptoms, risk, and recovery. 2022. https://www.cdc.gov/heartdisease/ heart_attack.htm [8] Vaswani D. Psychological Stress in Myocardi- al Infarction Patients. India Journal Cardiac Disease Women.2020; 5 (1): 34-5. doi.org/ of depression. According to the results of a quantitative cross-sectional study con- ducted in Iran about the prevalence of depression, anxiety, and stress disorders in elderly people living in Khoy, 74% of elderly people in the Khoy county had severe anxiety [18]. The majority of pa- tients who were suffering from diabetes and myocardial infarction had extremely severe levels of anxiety, the study found. Regarding the level of stress in both dis- eases, it was determined that the pa- tients had extremely high levels of stress. This finding was similar to that of the study about oxidative stress as the pri- mary cause of acute myocardial infarc- tion in diabetics, which established that stress is the primary factor in myocardial infarction (MI) in diabetics and has the worst prognosis [19]. The comparative levels of stress, anxiety, and depression between diabetic and myocardial infarc- tions were discussed in Table 3, which was the last one. It demonstrated that there were significant differences in pa- tients' levels of depression, anxiety, and stress between these two diseases, such that the level of depression among DM patients is lower than the level of depres- sion among MI patients. However, the conclusion was contradicted by two oth- er studies [20], [21]. Which established that the level of depression in both dis- eases is lower than anxiety and stress. The overall levels of worry and stress among DM patients are higher than the overall levels among MI patients. There- fore, in order to effectively provide psy- chological therapy to MI and DM pa- tients, it is necessary to take into account their psychological needs. 200 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. CONCLUSION References https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article (3):258. doi.org/10.1037/aap0000147 [17] Johansson I, Karlson BW, Grankvist G, Brink E. Disturbed sleep, fatigue, anxiety and de- pression in myocardial infarction patients. European journal of cardiovascular nursing. 2010 ;9 (3), P. 175-180. doi: 10.1016/ j.ejcnurse.2009.12.003 [18] Babazadeh T, Sarkhoshi R, Bahadori F, Mo- radi F, Shariat F. Prevalence of depression, anxiety and stress disorders in elderly peo- ple residing in Khoy, Iran (2014-2015). Jour- nal of Research in Clinical Medicine. 2016 ;4 (2):122-128. doi: 10.15171/jarcm.2016.020 [19] Filippo CD, Cuzzocrea S, Rossi F, Marfella R. and D'Amico M. Oxidative stress as the lead- ing cause of acute myocardial infarction in diabetics. Cardiovascular Drug Reviews Jour- nal. 2006; 24(2):77-87. doi: 10.1111/j.1527- 3466.2006. 00077.x [20] Norlund F, Lissaker C, Wallter J, Held C, Oll- son EMG. Factors associated with emotional distress in patients with myocardial infarc- tion: Results from the SWEDEHEART registry. European Journal of Preventive Cardiology 2018; 25(9). doi: 10.1177/2047487318770510 [21] Qui S, Sun H, Liu Y, Kanu JS, Li R, Yu Y et al. Prevalence and correlates of psychological distress among diabetes mellitus adults in the Jilin province in China: a cross- sectional study. Peer Journal. 2017; 10 (3): 5-11. doi: 10.7717/peerj.2869 10.1055/s-0040-1708575 [9] Pearson S, Wills K, Woods M and Warnecke E. Effects of Mindfulness on Psychological Distress and HbA1c in Peo- ple with Diabetes. Mindfulness Journal. 2018; 9 (2): 1615-6. doi.org/10.1007/ s12671-018-0908-1 [10] Sarkar S, Chadda RK, Kumar N and Narang R. Anxiety and depression in patients with myocardial infarction: findings from a cen- ter in India. General hospital psychiatry Journal. 2012; 34(2): P.160-166. doi.org/10.1016/ j.genhosppsych.2011.09.016 [11] Ma Y, Xiang Q, Yan Ch, Liao H, Wang J. Relationship Between Chronic Diseases and Depression: The Mediating effect of pain. BMC Psychiatry Journal. 2021; 436 (36). doi.org/10.1186/s12888-021-03428- 3 [12] Panthee B and Kritpracha C. Anxiety and Quality of life in Patients with Myocardial Infarction. Nurse Media Journal of Nurs- ing.2011; 1(1): P.105- 115.doi.org/10.14710/ nmjn.v1i1.750 [13] Bener A, OAA Al-Hamaq A and E Dafeeah. High prevalence of depression, anxiety and stress symptoms among diabetes mellitus patients. The Open Psychiatry Journal. 2011; Volume, 5(1). doi: 10.2174/1874354401105010005 [14] Hackett RA and Steptoe A. Type 2 diabetes mellitus and psychological stress a modifi- able risk factor. Nature Reviews Endocri- nology Journal. 2017; 13(9): P.547- 60. doi: 10.1038/nrendo.2017.64 [15] Henry JD, Crawford JR. The Short-Form Version of the Depression Anxiety Stress Scales (DASS-21). Construct validity and normative data in a large non-clinical sam- ple. British Journal of Clinical Psychology. 2005; 44 (2): 227-39. doi.org/10.1348/014466505X29657 [16] Seaton VA, Narcisse MR, Subica AM, Long CR, Matthews EE, McElfish PA. Sleep quali- ty partially mediates the association be- tween type 2 diabetes and psychological distress in Native Hawaiian and Pacific Islander adults in the United States. Asian American Journal of Psychology. 2019;10 201 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/