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Review

Anxiety, Distress and Stress among Patients with Diabetes during COVID-19 Pandemic: A Systematic Review and Meta-Analysis

1
UGC Orgiva, Granada-South Health Management Area, Andalusian Health Service, Calle La Madre s/n, Lanjarón, 18420 Granada, Spain
2
Faculty of Health Sciences, University of Granada, Cortadura del Valle s/n, 51001 Ceuta, Spain
3
Red Cross Nursing Center, University of Sevilla, Av. la Cruz Roja, 41009 Sevilla, Spain
4
Virgen de las Nieves University Hospital, Av. de las Fuerzas Armadas, 18014 Granada, Spain
5
UGC Iznalloz, Granada Metropolitan District, Andalusian Health Service, Calle Virgen de la Consolación, 12, 18015 Granada, Spain
6
Department of Statistics and Operations Research, University of Granada, Avda. Fuentenueva s/n, 18071 Granada, Spain
7
Instituto de Investigación Biosanitaria (ibs.GRANADA), 18012 Granada, Spain
8
Institute of Mathematics, University of Granada (IMAG), Ventanilla 11, 18001 Granada, Spain
9
Faculty of Health Sciences, University of Granada, Avenida de la Ilustración, 60, 18016 Granada, Spain
*
Author to whom correspondence should be addressed.
J. Pers. Med. 2022, 12(9), 1412; https://doi.org/10.3390/jpm12091412
Submission received: 28 July 2022 / Revised: 25 August 2022 / Accepted: 29 August 2022 / Published: 30 August 2022

Abstract

:
The prevalence of mental health disorders has increased during the COVID-19 pandemic. Patients with chronic diseases, such as diabetes, are a particularly vulnerable risk group. This study aims to assess the levels and prevalence of anxiety, distress, and stress in patients with diabetes during the COVID-19 pandemic. A systematic review was conducted in CINAHL, Cochrane, LILACS, Medline, SciELO, and Scopus in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Thirty-seven articles with a total of 13,932 diabetic patients were included. Five meta-analyses were performed. The prevalence of anxiety was 23% (95% CI = 19–28) in T1DM and 20% (95% CI = 6–40) in T2DM patients. For diabetes distress it was 41% (95% CI = 24–60) for T1DM and 36% in T2DM patients (95% CI = 2–84). For stress, the prevalence was 79% (95% CI = 49–98) in T1DM patients. People with diabetes have significant psychiatric comorbidity as well as psychological factors that negatively affect disease management, increasing their vulnerability in an emergency situation. To establish comprehensive care in diabetic patients addressing mental health is essential, as well as including specific policy interventions to reduce the potential psychological harm of the COVID-19 pandemic.

1. Introduction

The coronavirus infection (COVID-19) has become a global health problem since the beginning of 2020 [1]. The lockdown as well as the restrictions in the different waves of contagion have caused a negative impact on the health of the general population and especially on people who suffer from chronic diseases such as people with diabetes [2]. People with diabetes mellitus (DM) are a risk group, with high hospitalization and mortality rate, and this risk increases when there is COVID-19 infection [3].
The prevalence of mental health disturbances has increased at an alarming rate during the COVID-19 pandemic [4]. Patients with DM present multiple psychosocial factors, which together with the psychological stressors of a pandemic, such as quarantine, social distance, and fear of contagion, make this group even more vulnerable [5]. Mental disorders in DM patients reach figures of up to 50%, which predisposes to an increase in mental health disorders in the face of a pandemic situation that leads to difficulties in adapting psychologically [6]. Some reports show that up to 87% of DM type 2 patients indicate being “psychologically affected” [7].
Among the possible issues in psychological health, we can find a greater susceptibility to severe symptoms of depression and a feeling of loneliness, anxiety, stress, or diabetes stress, referring to negative emotions related to the disease such as feeling frustrated, desperate, or angry [8,9,10]. These comorbidities in DM patients can reduce self-care, adherence to treatment and engagement with health professionals, with a negative impact on disease management [11,12]. Several studies indicate that up to 50% of DM patients were afraid of possible contagion [7]. This situation, together with medical distrust, and frustration due to the difficulties in DM management, is related to a reduction in control visits and even more in the demand for assistance in non-emergencies problems, especially those related to mental health [13,14].
The lockdown and successive waves of restrictions have disrupted healthy lifestyle patterns and the ability to self-care [14]. Some studies report that up to 54% of chronic patients claim to have problems related to their usual treatment [15], and data from a survey conducted in 155 countries by the World Health Organization showed that diabetes treatment was partially or completely interrupted in 49% of the countries surveyed [16]. Unhealthy behaviours in DM patients with higher consumption of sugary drinks as well as a reduction in physical activity have also been reported [7]. Other studies report a reduction in self-monitoring of blood glucose; only 28% of patients regularly monitored glucose levels during the COVID-19 lockdown [17]. Given these data, some authors show a clear relationship between self-care deficit and an increase in the number of mental disorders [18].
Although there are several studies that analyse mental health in the general population, data about chronic disease patients and more specifically in patients with DM are still limited. There are studies focused on the treatment of diabetes and associated complications during the COVID-19 pandemic [5,19,20]; however, no systematic review and meta-analysis address psychological disturbances.
An analysis of levels of these variables, looking at the definition by the Medical Subject Headings, anxiety (“feelings or emotions of dread, apprehension and impending disaster”), distress (“negative emotional state with emotional and/or physical discomfort”), and stress (with emotional factors predominating) in the population with DM is necessary, since the number of DM patients affected by these problems before the COVID-19 pandemic was important [21] and these levels may have increased. This review analyses the data currently available in the pandemic scenario, in order to establish intervention strategies and address a psychosocial approach in people with DM during COVID-19. Therefore, the objective of this systematic review and meta-analysis was to analyse the levels and prevalence of anxiety, distress, and stress during the COVID-19 pandemic in diabetic patients.

2. Methods

2.1. Design

The review and meta-analysis were reported according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines [22] (see Supplementary Materials Table S1 for further information). The protocol was registered in PROSPERO (International Prospective Register of Systematic Reviews) with the registration number CRD42022325197.

2.2. Search Strategy

A search was performed in the following databases: the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO), the Cochrane Central Register of Controlled Trials (CENTRAL), LILACS (BIREME), Medline (Ovid), SciELO (BIREME), and Scopus (Elsevier). The search was done in July 2022 without restriction by language or publication date. The search terms used were: “(anxiety OR psychological distress OR stress) AND (diabetes OR chronic illness OR chronically ill OR non-communicable diseases) AND (SARS-CoV-2 OR coronavirus OR COVID-19)”.

2.3. Eligibility Criteria

Studies conducted during the COVID-19 pandemic were included with the following inclusion criteria: (1) original studies, (2) type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM), (3) assessing anxiety, distress, or stress symptoms (percentages, means, or median levels), (4) use of anxiety, distress, and stress validated measurement tool. There was no restriction by language or publication date.
Studies were excluded if they were: (1) letters to editors, conference paper review articles, and case reports, (2) articles with other types of diabetes (gestational, MODY, LADA), (3) articles including different chronic pathologies without indicating a number of participants with diabetes, (4) sample of patients with serious cognitive/neurological impairment or mental/physical disability.

2.4. Study Selection and Data Collection

First, two independent reviewers analysed titles and abstracts and then the full texts according to the inclusion criteria (Figure 1). A third author was consulted in case of disagreement.
Two authors extracted data from selected studies into an Excel spreadsheet, consulting with a third author in case of discrepancies. The following information was extracted from each study: (1) author, year of publication, country, (2) study design and period, (3) sample, (4) setting, (5) measuring instrument, (6) type of diabetes, (7) levels of anxiety, distress, or stress (percentage, mean, median) (Table 1).

2.5. Quality Assessment, Evidence Level and Grade of Recommendation

A quality assessment and bias analysis were carried out by two reviewers independently with a third reviewer consulted in case of disagreement.
The National Heart, Lung and Blood Institute quality assessment scale was used for bias assessment of observational studies [23] (Appendix A). The recommendations of the OCEBM were also used (Oxford Centre for Evidence-Based Medicine) to analyse the levels of evidence and grades of recommendation [24] (Table 1).

2.6. Data Analyses

A descriptive analysis was performed for the systematic review, extracting the variables in a data table.
For the meta-analysis, all the studies that presented data on the percentage of anxiety, diabetes distress, or stress measured through the same tool were used. Heterogeneity was assessed using the I2 index. Random effects meta-analysis were performed [25]. Sensitivity analysis and Egger’s regression test were used to assess bias in the studies.
Five meta-analyses were performed to estimate the prevalence of anxiety, diabetes distress or stress, and the corresponding confidence interval. StatsDirect software (StatsDirect Ltd., Cambridge, UK) was used for all statistical calculations.

3. Results

3.1. Characteristics of the Studies Included

The initial search found 3157 results. After deleting duplicates and reading the title and abstract, a total of 614 articles were selected. Finally, after reading the full text and analysing the inclusion criteria, 37 articles were included. The study search and selection process are shown in Figure 1.
All the studies found were observational (cross-sectional, retrospective, or prospective) and one was a case-control study. The total sample population consisted of 13,932 type 1 and type 2 diabetic patients. Most studies were conducted in Italy (n = 5), US (n = 5), followed by Saudi Arabia (n = 3), and Turkey (n = 3) (Table 1).
To measure anxiety, the most used questionnaires were the General Anxiety Disorder-7 (GAD-7) (n =7) and the Visual Analog Scale (VAS) for anxiety (n = 3). The remaining questionnaires used for anxiety were the Hospital Anxiety and Depression Scale (HADS), the Test of Depression and Anxiety Scale (TAD), Spence Children Anxiety Scale (SCAS), the Symptom Check List-revised anxiety subscale (SCL-ANX4), the General Health Questionnaire-12 items (GHQ-12), and the State-Trait Anxiety Inventory (STAI) (see Table 1).
The scales used to measure distress were the Diabetes Distress Scale (DDS) (n = 6), the Kessler Psychological Distress Scale (K10) (n = 3), the questionnaire Problem Areas in Diabetes-Distress item (PAID) (n = 3), and the Beirut Distress Scale (BDS22) (Table 1).
Finally, the stress measurement tools used were the Perceived Stress Scale (PSS) (n = 11), the Visual Analog Scale (VAS) for stress (n = 3), and the Impact of Event Scale Revised (IES-R) (Table 1).
The data were collected in different settings that included the collection of information through telephone surveys, online forms or through face-to-face at outpatient clinics, hospitals, or primary care centres. Most of the studies (n = 21) collected data during the first phase of the pandemic (January–June 2020).
The studies included had an adequate level of quality; according to the measurement tools applied there were no exclusions. The assessment and characteristics of the studies are represented in Table 1.
Table 1. Characteristics of the included studies (n = 37).
Table 1. Characteristics of the included studies (n = 37).
Author, Year, CountryStudy
/Period
SampleSettingScaleType of DiabetesAnxiety/Distress/Stress
M(SD)/M (IQR)
EL/RG
Abdelghani et al., [26], 2021, EgyptCross-sectional
June–September 2020
N = 200
Mean age 48.4 (13.7)
Female 63 %
Mean duration of DM 6.2 (5.3) years
Endocrinology outpatient clinicHADS-AnxietyT1DM
T2DM
Anxiety
8.8 (4.4)
2b/B
Abdoli et al. [27], 2021, US, Brazil, and IranCross-sectional
April–June 2020
N = 1788
US (n = 1099)
Brazil (n = 477)
Iran (n = 212)
Age >18 years
Female 78.28%
Online surveyDDST1DMDistress
No/little/moderate
US 86.6%
Brazil 69.2%
Iran 42.9%
High
US 13.40%
Brazil 30.8%
Iran 57.1%
2b/B
Agarwal et al. [28], 2020, IndiaCross-sectional
April–May 2020
N = 89
Mean age 19.61 (3.8)
Female 48.3%
Mean duration of DM 8.4 (5) years
Online surveyPSST1DMStress
Low 42.7%
Moderate 51.7%
Severe 5.6%
2b/B
Ajele et al., [29], 2022, NigeriaCross-sectional
April–July 2021
N = 223
Mean age 53.26 (11.05)
Female 26%
Outpatient clinicPAID-DDST1DM
T2DM
Distress
60.61 (29.51)
2b/B
Alkhormi et al., [30], 2022, Saudi ArabiaCross-sectional
August–-February 2022
N = 375
Female 51.7%
Diabetic center + primary healthcare centersGAD-7T2DMAnxiety
Normal 52.8%
Moderate-Severe 47.2%
2b/B
Alshareef et al. [31], 2020, Saudi ArabiaCross-sectional
May 2020
N = 394
Female 42.9%
Phone surveyK10T2DMDistress
9.78 (4.14)
2b/B
Alzubaidi et al. [32], 2022, United Arab EmiratesCross-sectional
February–July 2021
N = 206
Female 42.2%
Mean age 58.7 (11.2)
Mean duration of DM 15.7 (8) years
Phone surveyDDST2DMDistress
Low 85.9%
Moderate 10.7%
High 3.4%
2b/B
Bao [33], 2021, ChinaCross-sectional
January 2019–December 2020
N = 256
Range age 25-78 years
Female 57.4%
Department of EndocrinologyPAID-DDST2DMDistress
32.16 (12.13)
Moderate 37.89%
Severe 20.31%
2b/B
Barchetta et al. [34], 2020, ItalyObservational retrospective study
March–April 2020
N = 50
Mean age of 40.7 (13.5)
Female 38%
Diabetes outpatient clinicsPSST1DMStress
Low 26%
Moderate 60%
Severe 14%
2b/B
Büyükbayram et al. [35], 2022, TurkeyCross-sectional
January–July 2021
N = 184
Mean age of 51.77 (15.07)
Female 52.2%
Internal medicine clinicPSST2DMStress
23.82 (8.34)
2b/B
Caruso et al. [36], 2021, ItalyCross-sectional study
February–March 2020
N = 48
Mean age 42.4 (15.9)
Female 47.9%
Endocrinology unitGHQ-12T1DMAnxiety
4.5
Mild 50%
2b/B
Chao et al. [37], 2021, USObservational prospective study
July–December 2020
N = 2829
Mean age 75.6 (6)
Female 63.2%
Health centerGAD-7T2DMAnxiety
2.4 (3.5)
Moderate/Severe 5%
2b/B
Cusinato et al. [38], 2021, ItalyObservational retrospective study
March–April 2020
N = 117
Mean age 15.9 (2.3)
Female 44%
Mean duration of DM 7.9 (4.6) years
Pediatric Diabetes UnitTAD-AnxietyT1DMAnxiety
7%
2b/B
Cyranka et al., [39], 2021, PolandCross-sectional
March–May 2020
N = 49
Mean age 29.8 (8.9)
Female 75.5%
Mean duration of DM 16.2 (7.3) years
Outpatient clinicSTAI
PSS
T1DMAnxiety
STAI 39.7 (11)
Stress
PSS 21 (4.1)
2b/B
Di Dalmazi et al. [40], ItalyObservational retrospective study February–March 2020N = 76
Mean age 45 years
Female 48.7%
Mean duration of DM 22 years
Endocrinology and diabetes unitPSST1DMStress
14.5 (9.8–20)
2b/B
Di Riso et al. [41], 2021, ItalyCross-sectional
May–June 2020
N = 71
Mean age 11 (2.26) year
Female 46.6%
Pediatric Diabetes UnitSCAS-AnxietyT1DMAnxiety
16.7%
2b/B
Elhenawy & Eltonbary, [42], 2021, EgyptCross-sectional
March 2020
N = 115
Female 53.9%
Online surveyPSST1DMStress
Low 0%
Moderate 66.6%
Severe 33.4%
2b/B
Hosomi et al. [43], 2022, JapanObservational retrospective study
April–May 2020
N = 34
Mean age 59.1 (16)
Female 67.6%
Diabetes duration 14.5 (16)
Department of EndocrinologyVAS-StressT1DMStress
6.7 (2.1)
2b/B
Huang et al. [44], 2022, ChinaCross-sectional study
July–September 2020
N = 286ClinicsVAS- AnxietyT2DMAnxiety
5.3 (2.8)
2b/B
Kim et al. [45], 2022, USCross-sectional
June–December 2020
N = 84
Mean age 68.46 (5.41)
Female 54.76%
Mean duration of DM 13.89 (7.53) years
Online surveyDDST2DMDistress
1.35 (1.55)
0.63%
2b/B
Khari et al. [46], 2021, IranCross-sectional
September–December 2020
N = 427
Female 66%
Online surveyPSST1DM
T2DM
Stress
31.69 (5.88)
2b/B
Madsen et al., [47], 2021, DenmarkObservational prospective study
March 2020
N = 1366
Mean age 61.7 (12.8)
Female 44.5%
Online surveyDDS
SCL-ANX4
T1DM
T2DM
Distress
DDS 1.8 (1.00)
Low 75.4%
Moderate-High 24.6%
Anxiety
SCL-ANX4 0.5 (0.66)
<10% risk of anxiety 80.5%
20% risk of anxiety 14.6%
30% risk of anxiety 3.6%
40% risk of anxiety 1.1%
45% risk of anxiety 0.2%
2b/B
Magliah et al. [48], 2021, Saudi ArabiaCross-sectional
June 2020
N = 65
Mean age 30 (7.88)
Female 70.8%
Mean duration of DM 17.67 (6.89) years
Online surveyGAD-7T1DMAnxiety
None/minimal 56.9%
Mild 24.6%
Moderate 10.8%
Severe 7.7%
2b/B
Munekawa et al. [49], 2021, JapanCross-sectional
April–May 2020
N = 203
Mean age 67.4 (11.3)
Female 37.9%
Mean duration of DM 14.4 (10.1) year
Department of Endocrinology aVAS-StressT2DMStress
6.0 (1.7)
2b/B
Miller et al. [50], 2022, USObservational prospective study
March 2020
N = 41
Range age 10.3–19.1 years
Online surveyGAD-7
PSS
T1DMAnxiety
GAD-7 4.43 (4.63)
Stress
PSS 2.51 (0.71)
2b/B
Musche et al., [51], 2021, GermanyCross-sectional
April–June 2020
N = 240
Age > 18 years
Female 74.3%
Online surveyGAD-7T1DM
T2DM
Anxiety
T1DM (n = 169)
None/minimal 46.2%
Mild 30.8%
Moderate 17.2%
Severe 5.9%
T2DM (n = 74)
None/minimal 45.9%
Mild 27%
Moderate 14.9%
Severe 9%
2b/B
Myers et al., [52], 2021, USObservational prospective study
May–June 2020
N = 404
Mean age 51.46 years
Mean duration of DM 40.21 (17.70) years
Online surveyGAD-7
DDS
PSS
T1DM
T2DM
Anxiety
GAD-7
T1DM (n = 100) 6.81 (4.96)
Low-Mild 74%
Moderate-Severe 26%
T2DM (n = 304) 5.68 (5.50)
Low-Mild 75.99%
Moderate-Severe 24.01%

Distress
DDS
T1DM (n = 95) 2.61 (0.85)
Low 30.53%
Moderate 35.79%
High 33.68%
T2DM (n = 293) 2.43 (0.95)
Low 37.88%
Moderate 32.08%
High 30.03%

Stress
PSS
T1DM (n = 100) 17.59 (6.99)
Low 32%
Moderate 59%
High 9%
T2DM (n = 304) 15.82 (8.33)
Low 43.09%
Moderate 46.05%
High 10.86%
2b/B
Olickal et al. [53], 2020, IndiaCross-sectional
July–August 2020
N = 350
Female 22%
Phone surveyK10T2DMDistress
Low 67.4%
Moderate 30%
High 2.6%
2b/B
Naous et al. [54], 2022, LebanonCross-sectional
January–June 2021
N = 461
Median age 59 years
Female 47.4%
Median duration of DM 10 years
Hospitals and private clinicsK10T2DMDistress
26 (18-35)
Well 27.4%
Mild 19.1%
Moderate 15.1%
Severe 38.4%
2b/B
Nassar & Salameh, [55], 2021, LebanonCase-control study
April–May 2020
N = 72
Mean age 65.5 (10.5)
Female 48.6%
Phone surveyBDS22-AnxietyT2DMAnxiety
0.5 (1.1)
2b/B
Regeer et al. [56], 2021, NetherlandsCross-sectional
May 2020
N = 536
Mean age 65.9 (7.9)
Female 46%
Mean duration of DM 13.3 (8) years
Online surveyPSS
VAS-Anxiety
T2DMStress
PSS 12.98 (6.61)

Anxiety
VAS 4.2 (2.5)
2b/B
Ruissen et al. [57], 2021, NetherlandsObservational prospective study
March–June 2020
N = 435
Female 42%
Online surveyPSST1DM
T2DM
Stress
13.25 (6.45)
Elevated 34.1%
2b/B
Sacre et al. [58], 2021, AustraliaObservational prospective study
April–May 2020
N = 450
Mean age 66 (9)
Female 31%
Mean duration of DM 12 years
Phone/Online surveyGAD-7
PAID-DDS
T2DMAnxiety
GAD-7 2 (1.7–2.3)
Mild 16.4%
Moderate-Severe 8.4%

Distress
PAID 9 (8–10)
Severe 7.8%
2b/B
Shin et al. [59], 2021, KoreaCross-sectional
April–July 2020
N = 246
Mean age 73.8 (5.7)
Female 59.3%
Mean duration of DM 17.7 (8.8) years
Outpatient clinicIES-R-StressT2DMStress
6.4 (6.6)
Minimal 97.2%
Mild 1.2%
Moderate 1.2%
Severe 0.4%
2b/B
Silveira et al. [60], 2021, BrazilCross-sectional
May–July 2020
N = 436
North, Northeast, Central-West (n =118)
Southeast (n = 273)
South (n = 45)
Mean age 30.52 (9.22)
Female 83%
Mean duration of DM 15.29 (9.79) years
Online surveyDDST1DMDistress
Brazilian regions
North, Northeast, Central-West 2.72 (0.99)
No/Little 64.6%
Moderate/High 35.4%
Southeast 2.38 (1)
No/Little 70.8%
Moderate/High 29.2%
South 2.76 (1.13)
No/Little 68.8%
Moderate/High 31.2%
2b/B
Sisman et al. [61], 2021, TurkeyCross-sectionalN = 304
Mean age 42.1 (15.5)
Female 56%
Mean duration of DM 10.3 (8.5) years
Online surveyHADS-AnxietyT1DM
T2DM
Anxiety
T1DM 7.1 (3.6)
44.7%
T2DM 7.5 (4.3)
46.6%
2b/B
Utli & Vural Doğru [62], 2021, TurkeyCross-sectional
December 2020–April 2021
N = 378
Mean age 52.37 (11.37)
Female 37.3%
Endocrinology clinic + outpatients’ departmentVAS-Anxiety
VAS-Stress
T2DMAnxiety
VAS-Anxiety 7.32 (1.56)

Stress
VAS-Stress 7.06 (1.62)
2b/B
2b = evidence level from the OCEBM, B = recommendation grade from the OCEBM, BDS22 = Beirut Distress Scale, DDS = Diabetes Distress Scale, DM = Diabetes Mellitus, EL = Evidence level, GAD-7 = General Anxiety Disorder-7, GHQ-12 = General Health Questionnaire-12 items, HADS = Hospital Anxiety and Depression Scale, IES-R = Impact of Event Scale Revised, IQR = Interquartile range, K10 = Kessler Psychological Distress Scale, PAID = Problem Areas in Diabetes-Distress item, PSS = Perceived Stress Scale, RG = Recommendation grade, T1DM = Type 1 diabetes, T2DM = Type 2 diabetes, TAD = Test of Depression and Anxiety Scale, SCAS = Spence Children Anxiety Scale, SCL-ANX4 = Symptom Check List-revised anxiety subscale, SD = Standard deviation, STAI = State-Trait Anxiety Inventory, VAS = Visual Analog Scale.

3.2. Mean Levels of Anxiety, Distress and Stress

The average anxiety levels varied from minimal [37,44,47,50,56,58,61], to mild [26,36,52], to moderate [62], to severe [39]. For diabetes distress, the mean levels were low [31,45,47,55,58], moderate [33,52,60], and high [29,54]. The mean stress levels found ranged from minimal [50,56,57,59], moderate [35,39,40,43,49,52,62], and high [46].

3.3. Meta-Analysis

Five random effects meta-analyses were performed with a total of 1024 T1DM patients and 4238 T2DM patients.
For anxiety according to the GAD-7 tool, the prevalence found in T1DM patients for moderate and severe levels (GAD-7 ≥ 10 score) was 23% (95% CI = 19–28) with low heterogeneity (I2 = 0%). For T2DM patients, it was 20% (95% CI = 6–40) with high heterogeneity (I2 = 99%).
For diabetes distress measured with the DDS questionnaire, the prevalence found in T1DM patients for moderate and high levels (DDS > 2) was 41% (95% CI = 24–60) with high heterogeneity (I2 = 93%), and for T2DM patients 36% (95% CI = 2–84) with high heterogeneity (I2 = 99%).
Finally, stress levels measured with the PSS questionnaire showed a prevalence in T1DM patients for moderate and high levels (PSS ≥ 14) of 79% (95% CI = 49–98) with high heterogeneity (I2 = 97%). Egger’s test showed no publication bias, and no study was removed after sensitivity analysis.
Figure 2, Figure 3 and Figure 4 summarize the findings in relation to anxiety, distress and stress prevalence.

4. Discussion

This study suggests relevant data about psychological disorders in the diabetic population during the pandemic, with a meta-analytical prevalence estimation of anxiety of 23% in T1DM patients and 20% in T2DM patients, diabetes distress of 41% in T1DM and 36% in T2DM, and stress of 79% in T1DM.
Studies before the pandemic reported a prevalence of anxiety symptoms of 17.7% for T1DM patients [63], and of 18% for T2DM [64] being for diabetes distress of 42.1% in T1DM [65] and 29.4% in T2DM [66], and for the stress of 50% in T1DM [67]. These data suggest a significant increase in symptoms.
In addition, the prevalence of anxiety found in DM patients was higher than that of studies performed in other groups during the pandemic. In the elderly population, the prevalence of anxiety symptoms found ranged from 10.10% [68] to 21.6% of moderate/severe anxiety in general population [69,70]. Other studies in the general population stated DM as one of the main psychosocial problems with a prevalence of up to 40% [71]. Even a recent meta-analysis in the general population showed that the mean prevalence of anxiety and psychological stress was 38.1% and 37.5%, respectively [72].
More than half of the population with chronic pathology wished to have received additional information about the risks associated with their medical condition during the pandemic [15]. Several authors indicate that the provision of diabetes care was significantly disrupted during the pandemic [73], as corroborated by studies conducted in chronic patients where 52% of adults and 38% of children worsened their health condition during confinement [74].
During the pandemic, the psychological disorders of diabetic patients are often not recognized or underestimated, which can impair the quality of life and self-management of the disease [75]. Greater support for self-care is related to higher adherence to the expected regimen and life changes [12]; however, psychological stressors can have an adverse effect, for example in the loss of good glycaemic control [76].
This study suggests a higher prevalence of anxiety and stress diabetes in T1DM patients, as corroborated by other studies that found several factors related to worse mental health such as T1DM or the female gender [70,77]. Other factors such as age remain controversial; some studies reported worse data in younger patients [70,77,78,79,80], while for others the levels were higher in older age groups [81].
Regarding the negative results of the pandemic involving mental health, other related factors were the fear of contagion by COVID-19 [82,83] and COVID-19 anxiety syndrome [84]. Studies reported that up to 27.3% of people with DM experienced stress due to the spread of the COVID-19 pandemic and 20% experienced stress due to fear of drug shortages [85]. Even in hospitalized patients, stress levels reached up to 39.3% [75], being lower than those found in our meta-analysis.
Several studies highlight these facts as a reason for greater concern and related them to a reduced capacity in the provision of psychological support to this group [73]. Therefore, finding strategies to identify and reduce anxiety, distress, and stress, as well as multiple other possible disorders such as depression or loneliness should be a priority for diabetes services [86]. In this sense, several studies support the routine implementation of telemedicine [87], as well as increasing the capacity of primary care to provide telehealth services for diseases related to COVID-19 and for several other chronic medical conditions [88]. Studies that have used the telemedicine care model have found positive benefits, for example in a higher mean reduction in the HbA1c level compared with traditional care model [89], so it could also have positive results in the treatment of mental health disorders.
Although a large number of protocols have been developed to identify and recover people with DM infected by COVID-19, there is still a large gap in mental health care. Managing DM in the midst of the COVID-19 pandemic has proven to be a real challenge. To date little is known about how pandemics globally affect the psychosocial health of people with DM. This study is the first meta-analysis to provide an assessment of current levels of anxiety, distress, and stress since the onset of COVID-19 exclusively in patients with DM. It is necessary to clarify the current situation of mental health disorders in these patients in order to establish intervention strategies.

4.1. Limitations

This study has several limitations. First, the inclusion of T21DM and T2DM patients from different countries could increase the heterogeneity given the differences in the conditions of the health system, the management and follow-up of the disease, and also clinical variability in the percentage of female, type of diabetes, or measurement instrument. The heterogeneity in the meta-analyses were also high. However, the results of this study may allow understanding the impact of the pandemic on these patients as a start for future research. Another limitation is the inclusion of all the data since the start of the pandemic (different restrictions and waves of contagion), which could increase the heterogeneity. Finally, the different methods of data collection (by telephone, online, or face-to-face interviews) could lead to bias. This review has shown that there are important levels of anxiety, distress, and stress in people with diabetes during the COVID-19 pandemic. Future research should analyse which factors are related with these problems and how those levels can be reduced.

4.2. Implication for Practice and Research

The COVID-19 infection and confinement have a diverse impact on access to health services, psychosocial well-being, and self-management of people with diabetes, which must be contextualized to the responses and preparation of each country. Diabetes significantly increases the risk of emotional and behavioural disorders, especially in times of social crisis such as the one experienced with the COVID-19 pandemic [90]. Improving effective self-care behaviours that include healthy coping (healthy eating, being active, blood glucose control) are essential components to establishing optimal behaviour goals, which in turn will improve mental health outcomes [5]. Future research is needed to analyse the monitoring of levels as the pandemic progresses, as well as large multicentre longitudinal studies to avoid the above-mentioned limitations.

5. Conclusions

The prevalence found during the COVID-19 pandemic for anxiety ranged between 23% and 20%, for diabetes distress between 41% and 36%, and for stress it was 79%. People with diabetes have significant psychiatric comorbidity as well as psychological factors that negatively affect disease management, increasing their vulnerability in an emergency situation. To establish comprehensive care in diabetic patients addressing mental health is essential, as well as including specific policy interventions to reduce the potential psychological harm of the COVID-19 pandemic. Moreover, assessing the variables that can prevent or reduce the development of anxiety, distress, and stress in this population would be important.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/jpm12091412/s1, Supplementary Material Table S1: PRISMA 2020 checklist.

Author Contributions

Conceptualization, R.A.G.-L. and N.S.-M.; methodology, R.A.G.-L. and J.L.G.-U.; software, A.V.-S.; validation, N.S.-M. and J.L.R.-B.; formal analysis, J.L.R.-B.; resources, M.J.M.-J. and M.E.G.-B.; data curation, R.A.G.-L. and M.E.G.-B.; writing—original draft preparation, R.A.G.-L. and N.S.-M.; writing—review and editing, J.L.G.-U. and N.S.-M.; visualization, J.L.G.-U. and N.S.-M.; supervision, J.L.G.-U. and N.S.-M.; project administration J.L.G.-U. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Acknowledgments

This study forms part of the Doctoral Thesis of the first-named author within the Health Sciences Doctoral Program from the University of Murcia (Spain).

Conflicts of Interest

The authors declare no conflict of interest.

Appendix A

Table A1. Observational studies quality assessment with National Heart, Lung, and Blood Institute.
Table A1. Observational studies quality assessment with National Heart, Lung, and Blood Institute.
StudyQ1Q2Q3Q4Q5Q6Q7Q8Q9Q10Q11Q12Q13Q14
Abdelghani et al., [26], 2021, EgyptYYYYYNANANAYNAYNAYY
Abdoli et al. [27], 2021, US, Brazil, and IranYYYYNNANANAYNAYNANAY
Agarwal et al. [28], 2020, IndiaYYNRYNNANANANNAYNANAY
Ajele et al., [29], 2022, NigeriaYYYYNNANANAYNAYNANAN
Alkhormi et al., [30], 2022, Saudi ArabiaYYYYYNANANAYNAYNANAY
Alshareef et al. [31], 2020, Saudi ArabiaYYNRYNNANANAYNAYNANAY
Alzubaidi et al. [32], 2022, United Arab EmiratesYYYYNNANANAYNAYNANAN
Bao [33], 2021, China YYYYNNANANAYNAYNANAY
Barchetta et al. [34], 2020, ItalyYYNRYNNANANAYNAYNANAY
Büyükbayram et al. [35], 2022, TurkeyYYNRYYNANANAYNAYNANAY
Caruso et al. [36], 2021, ItalyYYYYNNANANAYNAYNANAN
Chao et al. [37], 2021, USYYYYNNANANAYNAYNANAY
Cusinato et al. [38], 2021, Italy YYNRYNNANANAYNAYNANAN
Cyranka et al., [39], 2021, Poland YYNRYNNANANAYNAYNANAN
Di Dalmazi et al. [40], ItalyYYYYNNANANAYNAYNANAY
Di Riso et al. [41], 2021, Italy YYYYNNANANAYNAYNANAY
Elhenawy and Eltonbary, [42], 2021, EgyptYYNRYNNANANAYNAYNANAY
Hosomi et al. [43], 2022, Japan YYYYNNANANAYNAYNANAY
Huang et al. [44], 2022, ChinaYYYYNNANANAYNAYNANAN
Kim et al. [45], 2022, USYYYYNNANANAYNAYNANAY
Khari et al. [46], 2021, IranYYNRYYNANANAYNAYNANAN
Madsen et al., [47], 2021, DenmarkYYYYNNANANAYNAYNANAN
Magliah et al. [48], 2021, Saudi ArabiaYYNRYNNANANAYNAYNANAY
Munekawa et al. [49], 2021, JapanYYYYNNANANAYNAYNANAY
Miller et al. [50], 2022, USYYYYNNANANAYNAYNANAY
Musche et al., [51], 2021, GermanyYYNRYNNANANAYNAYNANAY
Myers et al., [52], 2021, USYYNRYNNANANAYNAYNANAN
Olickal et al. [53], 2020, IndiaYYYYYNANANAYNAYNANAY
Naous et al. [54], 2022, LebanonYYNRYNNANANAYNAYNANAN
Nassar and Salameh, [55], 2021, LebanonYYNYNNANANAYNAYNANAN
Regeer et al. [56], 2021, NetherlandsYYYYNNANANAYNAYNANAY
Ruissen et al. [57], 2021, NetherlandsYYNRYNNANANAYNAYNANAY
Sacre et al. [58], 2021, AustraliaYYYYNNANANAYNAYNANAY
Shin et al. [59], 2021, KoreaYYYYNNANANAYNAYNANAY
Silveira et al. [60], 2021, Brazil YYNRYNNANANAYNAYNANAY
Sisman et al. [61], 2021, TurkeyYYNRYNNANANAYNAYNANAY
Utli and Vural Doğru [62], 2021, TurkeyYYYYYNANANAYNAYNANAY
N = No, Q = Question, Y = Yes.

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Figure 1. Flow diagram of the selection process.
Figure 1. Flow diagram of the selection process.
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Figure 2. Prevalence of anxiety in DM patients during COVID-19 pandemic (GAD-7). (a) Type 1 Diabetes [48,51,52], (b) Type 2 Diabetes [30,37,51,52,58].
Figure 2. Prevalence of anxiety in DM patients during COVID-19 pandemic (GAD-7). (a) Type 1 Diabetes [48,51,52], (b) Type 2 Diabetes [30,37,51,52,58].
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Figure 3. Prevalence of distress in DM patients during COVID-19 pandemic (DDS). (a) Type 1 Diabetes [52,60], (b) Type 2 Diabetes [32,52].
Figure 3. Prevalence of distress in DM patients during COVID-19 pandemic (DDS). (a) Type 1 Diabetes [52,60], (b) Type 2 Diabetes [32,52].
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Figure 4. Prevalence of stress in DM patients during COVID-19 pandemic (PSS) [28,34,42,52].
Figure 4. Prevalence of stress in DM patients during COVID-19 pandemic (PSS) [28,34,42,52].
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García-Lara, R.A.; Gómez-Urquiza, J.L.; Membrive-Jiménez, M.J.; Velando-Soriano, A.; Granados-Bolivar, M.E.; Romero-Béjar, J.L.; Suleiman-Martos, N. Anxiety, Distress and Stress among Patients with Diabetes during COVID-19 Pandemic: A Systematic Review and Meta-Analysis. J. Pers. Med. 2022, 12, 1412. https://doi.org/10.3390/jpm12091412

AMA Style

García-Lara RA, Gómez-Urquiza JL, Membrive-Jiménez MJ, Velando-Soriano A, Granados-Bolivar ME, Romero-Béjar JL, Suleiman-Martos N. Anxiety, Distress and Stress among Patients with Diabetes during COVID-19 Pandemic: A Systematic Review and Meta-Analysis. Journal of Personalized Medicine. 2022; 12(9):1412. https://doi.org/10.3390/jpm12091412

Chicago/Turabian Style

García-Lara, Rubén A., José L. Gómez-Urquiza, María José Membrive-Jiménez, Almudena Velando-Soriano, Monserrat E. Granados-Bolivar, José L. Romero-Béjar, and Nora Suleiman-Martos. 2022. "Anxiety, Distress and Stress among Patients with Diabetes during COVID-19 Pandemic: A Systematic Review and Meta-Analysis" Journal of Personalized Medicine 12, no. 9: 1412. https://doi.org/10.3390/jpm12091412

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