Yuan Y, Jian FJ, Wang L, Zhou BQ, Lin WE, Pang L, Wang Y. Psychological states in diabetic retinopathy: Social support correlates and risk factors. World J Psychiatry 2026; 16(4): 112523 [DOI: 10.5498/wjp.v16.i4.112523]
Corresponding Author of This Article
Yan Wang, PhD, Department of Ophthalmology, Guangdong Provincial Second Hospital of Traditional Chinese Medicine, No. 60 Hengfu Road, Guangzhou 510000, Guangdong Province, China. wangyan96000@126.com
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Psychology
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Observational Study
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Apr 19, 2026 (publication date) through Mar 30, 2026
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World Journal of Psychiatry
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Yuan Y, Jian FJ, Wang L, Zhou BQ, Lin WE, Pang L, Wang Y. Psychological states in diabetic retinopathy: Social support correlates and risk factors. World J Psychiatry 2026; 16(4): 112523 [DOI: 10.5498/wjp.v16.i4.112523]
Yuan Yuan, Lu Wang, Bing-Qian Zhou, Wan-Er Lin, Long Pang, Department of Ophthalmology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
Fang-Jie Jian, The Second Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
Yan Wang, Department of Ophthalmology, Guangdong Provincial Second Hospital of Traditional Chinese Medicine, Guangzhou 510000, Guangdong Province, China
Author contributions: Yuan Y designed the research and wrote the first manuscript; Yuan Y, Jian FJ, Wang L, Zhou BQ, Lin WE, Pang L, and Wang Y contributed to conceiving the research and analyzing data; Wang Y conducted the analysis and provided guidance for the research; all authors reviewed and approved the final manuscript.
Supported by the Special Research Project in Guangdong Provincial Hospital of Chinese Medicine, No. YN2023WSSQ06; Research and Innovation Fund of the Second Hospital of Guangdong Provincial Hospital of Traditional Chinese Medicine, No. SEZYY2024C01; and National Natural Science Foundation of China, No. 82405485.
Institutional review board statement: This study was approved by the Ethics Committee of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: No additional data are available.
Corresponding author: Yan Wang, PhD, Department of Ophthalmology, Guangdong Provincial Second Hospital of Traditional Chinese Medicine, No. 60 Hengfu Road, Guangzhou 510000, Guangdong Province, China. wangyan96000@126.com
Received: October 10, 2025 Revised: November 25, 2025 Accepted: January 4, 2026 Published online: April 19, 2026 Processing time: 170 Days and 19.6 Hours
Abstract
BACKGROUND
Diabetic retinopathy (DR) is closely and bidirectionally linked to psychological distress, yet research examining anxiety, depression, and social support among such patients remains limited.
AIM
To evaluate associations between psychological status and social support in DR and identify contributing risk factors.
METHODS
We enrolled 125 patients with DR treated at the Second Affiliated Hospital of Guangzhou University of Chinese Medicine (January 2022-January 2025). Anxiety, depression, and social support were assessed using the Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), and Social Support Rating Scale (SSRS). Spearman’s or Pearson’s correlation coefficients were used to analyze correlations between anxiety or depression and social support, and single- and multivariable regressions were used to identify key influencing factors.
RESULTS
Overall, 33.60% of participants experienced anxiety (HAMA: 11.1 ± 5.22) and 24.8% experienced depression (HAMD: 10.83 ± 5.75); the incidences of anxiety or depression and combined anxiety-depression were 49.60% and 8.8%, respectively. Mean SSRS scores were 34.37 ± 7.69, with sub-scores of 20.85 ± 6.59, 6.89 ± 5.92, and 6.63 ± 2.70. HAMA and HAMD scores were inversely correlated with SSRS (r = -0.396/-0.481, P < 0.001), a pattern that persisted in non-proliferative DR. Longer diabetes mellitus (DM) duration (≥ 8 years), visual disturbances, hypertension, and a family history of DM increased the likelihood of psychological distress, whereas social support (SSRS ≥ 35) had a protective effect.
CONCLUSION
Psychological distress affects nearly half of DR patients (49.60%). For those with non-proliferative DR, anxiety and depression show a strong negative association with social support. A prolonged DR course (≥ 8 years), visual impairment, hypertension, DM family history, and SSRS < 35 elevate distress risk.
Core Tip: This study analyzed patients with diabetic retinopathy (DR) to evaluate the correlations between psychological distress and social support and identify influencing factors. Nearly half of the cohort experienced anxiety or depression. In non-proliferative DR, anxiety and depression showed a significant negative correlation with social support, whereas findings in proliferative DR require validation in larger samples. Patients with a long diabetes mellitus duration, visual impairment, hypertension, a family history of diabetes mellitus, and low social support level were at heightened risk for psychological distress.
Citation: Yuan Y, Jian FJ, Wang L, Zhou BQ, Lin WE, Pang L, Wang Y. Psychological states in diabetic retinopathy: Social support correlates and risk factors. World J Psychiatry 2026; 16(4): 112523
Diabetic retinopathy (DR) is a common microvascular complication of diabetes mellitus (DM) characterized by progressive retinal injury. Its pathomechanism may involve microvascular abnormalities, mitochondrial dysfunction, inflammatory infiltration, necrocytosis, and microcirculatory disturbances[1]. DR remains a leading cause of blindness and visual impairment, affecting up to 40.0% of patients with DM, with more than 100 million cases worldwide[2]. Although most prevalent in adults aged 20-74, its incidence is rising among individuals aged 65-79, and shows a male predominance[3]. Current treatments - including anti-vascular endothelial growth factor therapy and laser surgery - offer certain efficacy but cannot fully prevent visual impairment[4]. Risk factors such as long DM duration, hyperglycemia, hypertension, rural residence, and negative emotions increase DR susceptibility; in turn, DR is bidirectionally linked to emotional disorders[5]. Anxiety and depression may worsen health behaviors, medication compliance, diet, sleep quality, and physical activity, thereby impeding glycemic control and elevating DR risk[6]. DR also affects photosensitive retinal ganglion cells and may influence mood and sleep through the hypothalamus-pituitary axis, accelerating retinal damage. Concurrently, DM-related hyperglycemia disrupts hippocampal function, the hypothalamus-pituitary axis, and emotional processing[7,8]. Social support can help mitigate anxiety and depression through emotional, informational, and practical assistance, strengthening psychological resilience and quality of life[9]. Support from family, friends, or pets has been shown to improve well-being and promote physical and mental health, regardless of stress level[10]. Despite this, few studies have examined anxiety and depression in relation to social support among patients with DR or identified associated risk factors. We hypothesize a significant association between psychological states and social support in DR cases and aim to clarify factors contributing to DR-related psychological distress to improve clinical management.
MATERIALS AND METHODS
General data
We conducted a retrospective analysis of 125 patients with DR treated at the Second Affiliated Hospital of Guangzhou University of Chinese Medicine from January 2022 to January 2025. Baseline characteristics showed no statistically significant intergroup differences (P > 0.05).
Patient selection criteria
Inclusion criteria included the following: Confirmed diagnoses of DM and DR[11]; normal cognitive-communicative function; and complete medical records. Exclusion criteria included the following: Optic neuropathies or other vision-impairing ocular morbidities; severe cardiovascular, pulmonary, renal, or endocrine disorders; secondary or gestational DM or impaired glucose tolerance; other ocular disorders, maxillofacial trauma, or anatomical abnormalities; malignancy; and major neurological or auditory deficits. A screening flowchart is provided in Figure 1.
Patients completed paper questionnaires. Trained researchers offered a standardized explanation of study aims and procedures. Patients filled out the questionnaires independently; researchers clarified items when needed. Complete questionnaires were collected immediately and double-entered by two researchers to ensure accuracy.
Endpoints
Anxiety and depression. Anxiety severity was assessed using the Hamilton Anxiety Scale (HAMA; 14 items)[12]. Each item is rated from 0 points to 4 points (0 = mild, 1 = moderate, 2 = severe, 3 = extremely severe, 4 = very severe). Score interpretation was as follows: No anxiety (< 7), possible (7-13), definite (14-20), significant (21-28), and severe anxiety (≥ 29). Depressive status was evaluated using the 17-item Hamilton Depression Scale (HAMD)[13], with diagnostic thresholds of: Normal (< 7), possible (7-16), definite (17-23), and severe depression (≥ 24 points).
Social support: Social support levels were assessed using the 10-item Social Support Rating Scale (SSRS)[14], which includes objective support (3 items), perceived support (4 items), and support utilization (3 items), totaling 12-66 points. Higher scores reflect stronger support. In this study, SSRS showed a Cronbach’s α of 0.716; validation research has reported α = 0.89 and test-retest reliability = 0.92. Total scores were categorized as minimal (12-22), intermediate (23-44), and robust support (45-66).
Other clinical data: Additional variables collected included age, sex, DM duration, disease stage, monthly per-capita household income, combined visual disturbances, comorbid hypertension, and familial DM history. Visual impairment followed the International Classification of Diseases criteria[15], defined as best-corrected visual acuity in the better-seeing eye of the logarithm of the minimum angle of resolution ≥ 0.48, encompassing moderate impairment, severe impairment, and blindness.
Statistical analysis
Statistical analyses were performed using SPSS 25.0. Continuous variables following a normal distribution were expressed as mean ± SD and compared using t-tests; categorical variables were summarized as n (%). Spearman or Pearson correlations assessed associations between anxiety/depression and social support. Factors influencing DR-related anxiety/depression were first examined using single-factor analyses and subsequently confirmed using binary logistic regression. Statistical significance was set at P < 0.05.
RESULTS
Psychological states of patients with DR
Among the patients with DR, the mean HAMA score was 11.1 ± 5.22. Of these, 53 (42.40%) fell within the “possible anxiety” range, and 5 (4.00%) reached significant anxiety. The mean HAMD score was 10.83 ± 5.75, with most patients showing possible depression (63 cases, 50.40%); only 2 cases (1.60%) showed severe depression. Overall, the rates of anxiety and depression were 33.60% and 24.8%, respectively (Tables 1, 2 and 3).
Table 1 Hamilton Anxiety Scale-based anxiety classification in diabetic retinopathy subjects.
Relationship between anxiety/depression and social support in patients with DR
Correlation revealed a negative correlation of SSRS with both HAMA (r = -0.396, P < 0.001) and HAMD (r = -0.481, P < 0.001) (Table 5). Stage-stratified analysis showed that these inverse correlations persisted in non-proliferative DR (NPDR) cases: HAMA (r = -0.435, P < 0.001) and HAMD (r = -0.463, P < 0.001). In patients with proliferative DR (PDR), although HAMA (r = -0.372, P = 0.061) and HAMD (r = -0.374, P = 0.060) also correlated negatively with SSRS, these correlations were not statistically significant.
Table 5 Relationship between anxiety/depression and social support in diabetic retinopathy patients.
Univariable and multivariable assessments of psychological distress contributors in DR
We divided the 125 patients into two groups: Those with anxiety or depression as the psychological distress group (n = 62), and the remaining patients as the non-psychological distress group (n = 63). Univariable analysis showed that psychological distress in patients with DR was significantly associated with DM duration, per-capita monthly household income, visual impairment, comorbid hypertension, familial DM history, and SSRS (all P < 0.05), whereas age, sex, and disease stage were not related (P > 0.05). Multivariable analysis further identified DM duration (≥ 8 years), visual impairment, hypertension, and familial DM history as risk factors for psychological distress, while an SSRS score ≥ 35 points served as a protective factor (all P < 0.05; Tables 6 and 7).
Table 6 Univariable evaluation of contributors to psychological distress states in diabetic retinopathy cases, n (%).
DR, a chronic inflammatory microvascular complication of DM, is marked by microaneurysms, irregular microvasculature, neovascularization, and other retinal microangiopathies. As the disease progresses, patients may develop macular hematoma, retinal detachment, or vitreous hemorrhage, which can ultimately lead to blindness[16,17]. To mitigate these adverse outcomes, this study focused on investigating psychological factors and social support. In our cohort of 125 patients with DR, the mean HAMA and HAMD scores were 11.1 ± 5.22 and 10.83 ± 5.75, respectively. Anxiety was confirmed in 33.6% and depression in 24.8%, with nearly half of the patients experiencing at least one form of psychological distress (49.60%). Qiu[18], using multiple scales, reported similar anxiety (32.0%-38.5%) and depression (25.1%-31.6%) rates in DR patients. Experimental work in affective-disorder rodent models suggests that the activation of the phosphoinositide 3-kinase/protein kinase B/mechanistic target of rapamycin pathway may contribute to anxiety- and depression-like behaviors, alongside changes in retinal morphology and physiology[19]. Additionally, the average SSRS score in our cohort was 34.37 ± 7.69, indicating predominantly intermediate support. Zhang et al[20] similarly reported moderate support (38.84 ± 7.33) in 210 DR surgical patients.
Our correlation analysis further showed that lower social support was associated with higher anxiety and depression in patients with DR. Subgroup analysis demonstrated that this negative correlation remained significant in NPDR cases. In PDR patients, although the negative trend persisted, the correlations did not reach statistical significance, likely due to the small sample size. Zhan et al[21] reported a similarly strong inverse association between social support and depression/anxiety in individuals with Coronavirus Disease 2019. Wu et al[22] found that among diabetic patients, depression was inversely associated with social support and disease-control parameters, and anxiety was associated with weight and combined disease-control indicators - findings that supplement our results. Mo et al[23] observed that resilience mediated the effect of social support on depression in patients with strabismus, offering a possible mechanism relevant to DR. Delgado-Galeano et al[24] further noted that social support improves recovery, treatment compliance, and outcomes in diabetic patients with depression. Another study[25] reported that parental resilience among children with retinopathy of prematurity correlated negatively with anxiety and depression and positively with social support, again indicating that resilience may mediate the support-distress relationship. Although this study did not directly compare the strength of each social support dimension, subjective support may reasonably play a more central role. First, when objective support and support utilization are limited, an individual’s subjective perception of support becomes crucial for buffering psychological stress. Second, this view aligns with the cognitive-stress model in chronic disease psychology[26], which emphasizes that the subjective evaluation of life events largely determines emotional responses. Future works should therefore assess the independent effects of subjective, objective, and utilization-based support using multivariate models. If validated, such findings would indicate that psychological interventions should not only provide objective assistance, but also enhance patients’ sense of subjective support, such as through cognitive-based strategies that reduce helplessness and improve psychological resilience.
Single- and multi-factor regression analyses showed that DM duration ≥ 8 years, combined visual disturbances, hypertension, and a familial DM history were significant predictors of psychological distress in patients with DR, whereas an SSRS score ≥ 35 mitigated these psychological risks. Notably, in the multivariable model, per capita monthly household income approached significance (P = 0.059). Although slightly above the conventional 0.05 threshold, its odds ratio value (0.365) implies that higher income may confer psychological protection. This trend warrants attention as its lack of statistical significance may reflect limited sample size, income categorization, or residual confounding. Larger studies should clarify the exact role of household per capita monthly income in the psychological distress of patients with DR. Consistent with our findings, Gao and Liu[15] identified visual impairments, prolonged DM duration, DM heredity, and hypertension as contributors to psychological distress. Zhang et al[27] further reported that rural residence, hypertension, and visual impairment predisposed patients with DR to depression, while self-care capacity and diastolic blood pressure influenced anxiety, complementing our observations. Additional evidence supports social support as an independent protective factor against anxiety and depression in DR[28]. Ju and Wang[29] also found that sex, financial status, and DM chronicity predicted mood disorders after vitrectomy in DR, thereby expanding our conclusions. Collectively, these findings underscore the need for routine psychological screening in DR patients with prolonged disease duration, visual impairment, or hypertension, and for integrating social support assessment into comprehensive management to facilitate timely intervention. Future studies should delineate how social support exerts protective effects across different DR stages to inform targeted psychological and social intervention strategies.
CONCLUSION
In this DR cohort (n = 125), anxiety (33.60%) and depression (24.8%) were predominantly mild, and social support levels averaged in the intermediate range. The negative correlation between social support and psychological distress in patients with DR varied by disease stage and requires validation in larger PDR samples. Psychological distress was markedly elevated in patients with DM duration > 8 years, visual disturbances, hypertension, a familial DM history, or an SSRS score < 35 points.
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Footnotes
Peer review: Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Psychology
Country of origin: China
Peer-review report’s classification
Scientific quality: Grade B, Grade C
Novelty: Grade B, Grade C
Creativity or innovation: Grade B, Grade B
Scientific significance: Grade C, Grade C
P-Reviewer: Murashita K, PhD, Japan; Oakley BFM, MD, United Kingdom S-Editor: Bai SR L-Editor: A P-Editor: Wang WB
