Depression is a frequent comorbidity in patients with type 2 diabetes mellitus (T2DM) and affects disease control, self-management and clinical outcomes. While depressive symptoms in T2DM are widely reported, less is known about differences in depression severity between urban and rural primary care settings, where access to healthcare resources and mental health services may differ substantially.To compare the severity of depressive symptoms and associated clinical characteristics among patients with T2DM receiving primary care in urban and rural settings, and to explore implications for early detection and management of depression in primary care.To compare the severity of depressive symptoms and associated clinical characteristics among patients with T2DM receiving primary care in urban and rural settings, and to explore implications for early detection and management of depression in primary care.Among 380 patients included, depressive symptoms were identified in 57.7%. Mild depression predominated overall; however, marked urban–rural differences in severity were observed. Patients in rural primary care settings demonstrated a substantially higher proportion of moderate-to-severe and severe depression compared to urban patients, among whom mild forms were more common. Poor glycaemic control (HbA1c >7.5%) and diabetes-related complications were more frequent in the rural group and were strongly associated with higher depression severity. All patients with poorly controlled diabetes exhibited depressive symptoms, with severe forms clustering predominantly in rural settings.Although overall prevalence was comparable, rural patients with T2DM experienced more severe depressive symptoms. These findings suggest delayed recognition of depression, limited access to mental health services, and a higher clinical and psychosocial burden in rural primary care settingsPatients with T2DM in rural primary care are at increased risk of moderate-to-severe depression compared to urban populations. Integrating routine depression screening into diabetes care, strengthening mental health competencies of primary care physicians, and prioritising rural settings may reduce inequities, improve outcomes, and support patient-centred chronic disease management.