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 Table of Contents  
Year : 2019  |  Volume : 3  |  Issue : 4  |  Page : 147-152

Prevalence of psychological distress in type ii diabetes in China: A systematic review and meta-analysis

1 National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University; School of Public Health, Peking University, Beijing, China
2 National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, China
3 National Clinical Research Center for Mental Disorders, Institute of Mental Health, Key Laboratory of Mental Health and Peking University Sixth Hospital, Peking University; Peking-Tsinghua Center for Life Sciences and PKU-IDG/McGovern Institute for Brain Research, Peking University, Beijing, China

Date of Submission12-Oct-2019
Date of Acceptance26-Nov-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Prof. Yan-Ping Bao
National Institute on Drug Dependence, Peking University, 38 Xueyuan Road, Beijing 100191
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hm.hm_67_19

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Type 2 diabetes mellitus (T2DM) patients are commonly comorbid with psychological distress, such as depressive symptoms, anxiety symptoms, and diabetes distress, which cause great health and economic burden. However, the estimated prevalence of this psychological comorbidity is quite different between studies. Our aim is to estimate the pooled prevalence of depressive symptoms, anxiety symptoms, and diabetes distress in T2DM patients in China. Two Chinese academic databases (China National Knowledge Infrastructure and Wanfang) and two English academic databases (PubMed and Embase) were systematically searched for studies with information on the prevalence of depressive symptoms, anxiety symptoms, and diabetes distress among Chinese T2DM patients published from inception to April 20, 2018. Random-effects meta-analysis was performed to estimate the pooled prevalence. Data were extracted from 80 cross-sectional studies involving 31874 Chinese T2DM patients. The pooled prevalence of depressive symptoms, anxiety symptoms, and diabetes distress were 37.8% (95% confidence interval [CI] 34.6–41.0), 28.9% (95% CI 21.0–36.9), and 50.5% (95% CI 42.4–58.7), respectively. Patients aged 60 years or older have higher prevalence than patients aged <60 years for depressive symptoms, anxiety symptoms, or diabetes distress. Much attention should be paid to the psychological conditions of Chinese T2DM patients, especially for those patients aged 60 years or older in T2DM management.

Keywords: Anxiety symptoms, depressive symptoms, diabetes distress, meta-analysis, type II diabetes

How to cite this article:
Li JQ, Wang YH, Lu QD, Xu YY, Shi J, Lu L, Bao YP. Prevalence of psychological distress in type ii diabetes in China: A systematic review and meta-analysis. Heart Mind 2019;3:147-52

How to cite this URL:
Li JQ, Wang YH, Lu QD, Xu YY, Shi J, Lu L, Bao YP. Prevalence of psychological distress in type ii diabetes in China: A systematic review and meta-analysis. Heart Mind [serial online] 2019 [cited 2022 Oct 3];3:147-52. Available from: http://www.heartmindjournal.org/text.asp?2019/3/4/147/273849

  Introduction Top

Diabetes is on the rise globally. According to the reports of International Diabetes Federation,[1] 425 million people aged 20–79 years worldwide had diabetes in 2017, and this number was estimated to increase to 629 million by 2045. For China, 114.4 million people had diabetes in 2017, which was the highest number of diabetic people in the world. China also had the largest number of undiagnosed diabetes people, which was 61.3 million. These caused much disease burden[2] and economic burden.[3]

Affected by disease and treatment, people with diabetes commonly have negative emotional experience. In addition to general longstanding concerned psychological distress (depressive and anxiety symptoms), another specific form of psychological distress – diabetes distress has gradually attracted attention of medical personnel. Diabetes distress or diabetes-related psychological distress is a relatively newly recognized concept. It is specific to living with diabetes and constitutes anxiety, depression, stress, frustration, worry, and other emotions, mainly coming from patients' self-awareness of the disease and difficulties in daily diabetes management.[4]

Both general psychological distress (depressive and anxiety symptoms) and diabetes distress have been shown to have a negative impact on type 2 diabetes mellitus (T2DM) patients. T2DM patients who have depression are more likely to have unhealthy diet and physical inactivity. They are also more likely to have nonadherence to medication and bad diabetes control. A recent research[5] even found significant association between depressive symptoms and all-cause mortality among T2DM patients. Another study[6] found that diabetes distress had a greater effect on T2DM patients than depression. It was significantly associated with impaired blood glucose control and affected patients' self-management, self-efficacy, and quality of life.

However, prevalence estimates of psychological distress vary across studies, ranging from 18% to 52% in T2DM patients.[7] Studies may report quite different prevalence findings about psychological distress among T2DM patients depending on age, proportion of gender,[8] course of disease,[9] body mass index,[10] and so on. A reliable estimation of psychological distress prevalence in T2DM patients is important for exerting more efforts to prevent, treat, and even explore cause of psychological distress among them. Therefore, we conducted this systematic review and meta-analysis of published studies of anxiety symptoms, depressive symptoms, and diabetes distress in T2DM patients in China.

  Methods Top

Search strategy and selection criteria

Preferred Reporting Items for Systematic Reviews and Meta-Analyses[11] and Meta-Analyses of Observational Studies in Epidemiology[12] guidelines were followed. Cross-sectional studies published from inception to April 20, 2018, that reported prevalence of psychological distress in T2DM patients were identified by searching two Chinese databases (China National Knowledge Infrastructure [CNKI] and Wanfang) and two English databases (PubMed and Embase). Predefined search strings were “depression or anxiety or psychological distress,” “T2DM,” and “prevalence.” Studies were included if they met the following criteria: (1) included Chinese T2DM patients aged 18 years or older, (2) clearly diagnosed T2DM, (3) measured the prevalence of psychological distress using a validated method, (4) reported prevalence or provided data for calculation of the prevalence, and (5) used language: English or Chinese. The exclusion criteria for selecting studies were as follows: (1) review, comment, lecture, or dissertation and (2) repeated publication or the same study. The largest sample size of the literature was included if repetitive researches were from the same sample population.

Study selection and data extraction

After removing duplicates, two reviewers independently checked titles and abstracts of all searched articles. Then they read the full texts to determine eligibility according to inclusion and exclusion criteria. They would discuss with the third reviewer if they had any disagreement. Two trained reviewers independently extracted the following data from each eligible study using a standardized form: psychological distress information (prevalence, scales, and cutoff value), study characteristics (publication year and study province) and sample characteristics (sample size, source of recruitment, mean age, and percentage of female).

Quality assessment

An eight-domain items tool[13] was used to assess the quality of the epidemiologic studies included in systematic review and meta-analysis.[14],[15] According to this tool, a study can be scored a total maximum of 8 points in the following domains: population definition, sampling method, response rate ≥70%, description of nonresponders, representative sample, standardized data collection, validated scale, confidence interval (CI), or standard error reported. The answer of each item was “yes,” “no,” or “unclear.” The item was scored 1 only for the answer “yes.” Each study was evaluated as low quality if the score attainment was 0–2, moderate quality if the score attainment was 3–5, and high quality if the score attainment was 6–8.

Data analysis

The primary estimation was to pool the study-specific prevalence of depressive symptoms, anxiety symptoms, or diabetes distress using random-effects meta-analysis for expected large heterogeneity between different studies.[15],[16] Heterogeneity was assessed by using I2-statistic or Cochran's Q test, where I2 statistics (>50%) or Cochrane Q (P < 0.10) was considered as an indication of significance. Subgroup analysis was conducted according to the following study-level characteristics: source of patients (hospital vs. community), study region (North vs. South), gender composition (proportion of female ≥ 50% vs. <50%), mean age (≥60 vs. <60), and publication year (≥2010 vs. <2010). The effect of each individual study on the overall prevalence was explored by excluding each study sequentially in sensitivity analysis. Publication bias was assessed by the aid of funnel plot and Egger's test. All analyses above were carried out with Stata® Statistical Software Package, Version 13.1 (Stata Corp LP, College Station, Texas, USA). Statistical tests were two side, and the significant level was set by a threshold of P < 0.05.

  Results Top

Selection and characteristics of included articles

1591 articles were found according to database search (CNKI: 609, WanFang: 856, PubMed: 24, Embase: 102), of which 1149 titles and abstracts were then screened for eligibility with 442 duplicates removed. After reviewing these, 137 potential studies were identified for full text peer review, and 80 studies of them provided sufficient data and were eligible for inclusion [Figure 1]. 57 studies reported prevalence of depressive symptoms with the pooled sample size of 25,183, 13 studies reported prevalence of anxiety symptoms with the pooled sample size of 3649, and 23 studies reported prevalence of diabetes distress with the pooled sample size of 7342. Eight studies reported depressive and anxiety symptoms, 3 studies reported depressive symptoms and diabetes distress, and 1 study reported depressive symptoms, anxiety symptoms, and diabetes distress at the same time. 61 studies were conducted in hospital-based settings, while 17 studies were from community-based settings and 2 studies used population-based sample. 41 studies were carried out in southern China while 39 studies in northern China. The median sample size per study was 219 (ranges from 68 to 2966). 41 studies used the Zung Self-rating Depression Scale to assess depressive symptoms, 6 studies used the Hamilton Depression Scale, 5 studies used the Beck Depression Inventory, 3 studies used the Center for Epidemiologic Studies Depression Scale, and 2 studies used the Hospital Anxiety and Depression Scale (HADS). 11 studies used the Zung Self-rating Anxiety Scale (SAS) to assess anxiety symptoms and 2 studies used the HADS. 21 studies used the diabetes distress scale to assess diabetes distress and 2 studies used the problem areas in diabetes scales. The publication year ranged from 2002 to 2018. [Table S1][Additional file 1] in the supplement material summarized the characteristics of included studies in our analysis.
Figure 1: Flow chart of the identification of eligible studies

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The quality assessment scores ranged from 1 to 8. Of 8 possible points, 19 studies got 1–2 points, 52 studies got 3–5 points, and 9 studies got 6–8 points. 88.8% studies were ranked as moderate to high quality. Detailed description of the quality of studies is shown in [Table S2][Additional file 2].

Pooled prevalence of psychological distress among T2DM patients

As shown in [Table 1], the meta-analytic pooled prevalence of depressive symptoms in Chinese T2DM patients reported by 57 studies was 37.8% (95% CI 34.6–41.0), the pooled prevalence of anxiety symptoms from 13 studies was 28.9% (95% CI 21.0–36.9), and the pooled prevalence of diabetes distress from 23 studies was 50.5% (95% CI 42.4–58.7). Since there was substantial between-study heterogeneity, random-effect model was used for meta-analysis.
Table 1: The subgroup analysis of pooled prevalence of depressive symptoms, anxiety symptoms, and diabetes distress in type 2 diabetes mellitus patients

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Subgroup analysis

Pooled prevalence of depressive symptoms, anxiety symptoms, or diabetes distress were also estimated by different study-level characteristics. Patients aged 60 years or older have higher prevalence than patients aged <60 years either for depressive symptoms (42.0% vs. 37.8%), anxiety symptoms (30.7% vs. 27.3%), or diabetes distress (57.8% vs. 48.6%). Significant difference in prevalence estimates was noted between hospital-based studies versus community-based studies (50.0% [95% CI, 23.9–34.9] vs. 25.3% [95% CI, 20.8–29.8], P < 0.05) for anxiety symptoms and studies in northern region of China versus southern region (34.2% [95% CI, 30.8–37.7] vs. 42.0% [95% CI, 37.1–46.9], P < 0.05) for depressive symptoms. Source of patients, region, sex, age, and publication year did not have any significant moderating association with the prevalence of diabetes distress. The prevalence of specific psychological distress (diabetes distress) in Chinese T2DM patients was higher than general psychological distress (depressive symptoms or anxiety symptoms) in all study-level subgroup.

Publication bias

Publication bias was detected by the funnel plots and Egger's tests. Visual examination of funnel plot suggested some publication bias for the prevalence of anxiety symptoms [Figure 2]b and prevalence of diabetes distress [Figure 2]c, which was confirmed by Egger's test. No publication bias was revealed on the prevalence of depressive symptoms in T2DM patients [Egger's test: T = −0.66, P = 0.51; [Figure 2]a.
Figure 2: (a) Funnel plot of publication bias for 57 studies with available data on depressive symptoms in type 2 diabetes mellitus patients, (b) funnel plot of publication bias for 13 studies with available data on anxiety symptoms in type 2 diabetes mellitus patients, (c) funnel plot of publication bias for 23 studies with available data on diabetes distress in type 2 diabetes mellitus patients

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  Discussion Top

According to our analysis, psychological distress is a common problem among Chinese T2DM patients, which have a great impact on personal health and social disease burden. It is reported that individuals with T2DM and psychological distress condition are at risk of poorer diabetes control,[17] hyperglycemia,[18] diabetic complications,[19] and poor quality of life,[20] which will lead to more mortality[21] and increase healthcare costs[22] in contrast to people with T2DM alone. Our findings highlight an important issue for treatment and prevention of psychological distress in T2DM patients.

This systematic review and meta-analysis demonstrated that 37.8% (95% CI 34.6–41.0) T2DM patients had depressive symptoms and 50.5% (95% CI 42.4–58.7) T2DM patients had diabetes distress. The result was higher than the prevalence reported elsewhere. International Prevalence and Treatment of Diabetes and Depression – a recent completed multicenter study[23] found that the prevalence of depression, moderate-to-severe depressive symptoms, and diabetes-related distress in T2DM patients were 10.6%, 17.0%, and 12.8%, respectively. In addition, one meta-analysis[13] demonstrated an overall prevalence of 36.0% for diabetes distress in T2DM patients. The prevalence of 17.0% and 36.0% could be seen as a global epidemic of depressive symptoms and diabetes distress. The possible reason for disparity between this and our current result could be the high prevalence of mental health problems in developing countries like China compared to the developed countries.[24] Furthermore, a recent meta-analysis[25] showed that the pooled prevalence of depression in T2DM patients, from one developing country – India, was 38% (95% CI 31.0–45.0), which was almost the same with our estimation of pooled prevalence of 37.8% for depressive symptoms in China. Our results also showed that 28.9% (95% CI 21.0–36.9) of T2DM patients have anxiety symptoms. This result was higher than a previous comprehensive review which indicated that the prevalence of clinically significant anxiety among T2DM patients was 14.0%.[26] The explanation of difference might be that the included studies of that review used structured or semi-structured diagnostic interviews, but self-report measures (SAS and HADS) were used in our analysis. However, our results of anxiety symptoms were lower than another study which indicated that the prevalence in a Mexican population was 55.10%.[27] Different culture background, various methods used for assessing anxiety, sociocultural attitude, different levels of treatment, and prevention of mental health may partly explain the variation. Other reasons may be that T2DM patients in Mexican study had longer duration and more complications; thus, they were more prone to develop anxiety symptoms.

In our study, psychological distress (depressive symptoms, anxiety symptoms, or diabetes distress) was noted to be more prevalent in aged T2DM patients compared to young T2DM patients. The pattern may be explained by the fact that older patients were at a later stage of T2DM and they were more likely to develop complications of diabetes compared to the young patients, which resulted in rise of psychological distress. Interestingly, previous study[28] has proven that the relationship between duration of diabetes and depression is unique: many cases of depression emerge soon after the diabetes diagnosis, and then, the incidence decreases with time, and the number gets higher again at late stage of diabetes with complications increasing.

There is no robust reason to explain the significant difference for anxiety symptoms between T2DM patients from hospital and community since 11 of 13 studies were conducted in hospital. Subgroup analysis revealed that the prevalence of depressive symptoms was significantly higher in south of China. Although it was found that the psychological problems caused by T2DM were related to the personality characteristics of patients, especially those patients with higher mental quality and emotional instability were more likely to cause psychological problems[29], no study has proved that T2DM patients in the south of China and north of China often exhibit different personality characteristics; thus, the results of different prevalence in different region need further population-based research to explore.

Previous research[4] has drawn a distinction between the two conditions suggesting that diabetes distress was more widespread than general psychological distress, which was our results revealed. In addition, the research[30] found that diabetes distress was distinct from depression and was related to disease burden of management, which may cause diabetes distress remaining persistent over time. Hence, the strategy for management of diabetes distress needed more concerns from clinician side.

Several limitations should be considered when interpreting the results of this study. First, the major limitation was that publication bias existed according to the funnel plots, especially the wide dispersion of the data shown in [Figure 2]b and c. Second, the overall study quality assessment indicated a moderate risk of bias, with the majority of studies were rated as moderate quality. Third, a substantial heterogeneity has not been explained in the studies combined although we used random-effects models and subgroup analysis to examine several variables. Finally, the different methods and cutoff scores used to determine the prevalence could not be precise. Future meta-analysis may conduct an exclusive search to find gray literature and unpublished data if possible. More multicenter survey with big sample size may help to provide a more accurate estimate of the prevalence of psychological distress in T2DM patients in China.

  Conclusions Top

The overall prevalence of depressive symptoms, anxiety symptoms, and diabetes distress among Chinese T2DM patients were high. Early detection and intervention for psychological distress should be taken among T2DM patients to improve the health and quality of this population. Comprehensive interventions strategies were warranted to prevent and manage psychological distress among T2DM patients.


We are grateful to the Peking University for providing us a wide range of available online databases.

This study was supported by the Thirteenth Five-Year Program of the Chinese Ministry of Science and Technology (no. 2016YFC0800907 and no. 2017YFC0803608) and NSFC-CIHR Joint Health Research Program (no. 81761128036).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1]

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