We are writing to express our profound appreciation for the insightful and comprehensive systematic review and meta-analysis, ‘Suicide Death, Suicidal Ideation and Suicide Attempt in Patients with Diabetes’ (Fan et al. 2024) The authors should be commended for addressing a critically underexplored intersection of mental and physical health, which has significant public health implications. The synthesis of data across multiple studies provides robust evidence of an elevated risk of suicidal behaviours and ideation in patients with diabetes. The meta-analytical approach enhances statistical power and offers precise effect size estimates, allowing for greater confidence in the findings. Additionally, the authors' stratification by demographic and clinical factors, such as year of publication, gender and type of diabetes, adds insights into subgroups that may be more vulnerable to suicidal outcomes. While the study unravels the association between diabetes and suicide, we would like to offer some reflections and considerations to further deepen the discourse on this important topic.

While the study highlights the impact of diabetes on suicidal behaviours, it is crucial to demonstrate the bidirectional relationship between diabetes and mental health to better understand the underlying mechanisms. Depression and anxiety, which are prevalent among individuals with diabetes (Palizgir, Bakhtiari, and Esteghamati 2013; Woon et al. 2020), are well-established risk factors for suicidal ideation and behaviours. These mental health conditions can arise due to the chronic stress of managing diabetes, including the constant vigilance required for blood glucose monitoring, dietary restrictions and fear of long-term complications. Furthermore, the social stigma associated with diabetes, particularly in younger individuals or those with lifestyle-related type 2 diabetes, may compound feelings of isolation and psychological distress. Simultaneously, the presence of depression and anxiety can have a deleterious effect on diabetes management by reducing adherence to prescribed regimens, including medication, lifestyle modifications and follow-up appointments. Poor mental health may also exacerbate glycaemic control through physiological pathways, such as heightened cortisol levels due to chronic stress, which can interfere with insulin sensitivity. These interactions create a vicious cycle where poor mental health worsens diabetes outcomes, which, in turn, increases psychological burden and the risk of suicidal thoughts or attempts. A clearer delineation of this complex interplay between diabetes and mental health could inform the development of holistic, integrated care models. Such models would prioritise both physical and psychological well-being, leveraging multidisciplinary teams to address the full spectrum of needs for individuals living with diabetes. Future research should explore these bidirectional dynamics longitudinally to guide targeted interventions and policy initiatives.

The meta-analysis could benefit from a more detailed exploration of socioeconomic and cultural factors that may mediate the association between diabetes and suicide. Socioeconomic determinants, such as income inequality, education levels, employment status and healthcare access, can significantly influence both the physical and mental health outcomes of individuals with diabetes. Limited access to affordable healthcare may delay the diagnosis and management of diabetes, leading to more severe complications and heightened psychological distress, which could increase the risk of suicidal ideation or behaviour. Moreover, financial stress associated with the high cost of diabetes care, particularly for insulin-dependent patients, can exacerbate mental health challenges, further increasing the vulnerability of affected individuals. Cultural stigma also plays a critical role in shaping these outcomes. In many societies, diabetes is viewed as a condition linked to poor lifestyle choices, leading to blame and shame for those diagnosed. This stigma is compounded when mental illness is involved, creating dual layers of social isolation and preventing individuals from seeking help for either condition. In high-income countries, patients may have greater access to mental health support integrated into diabetes care, while in low- and middle-income countries, systemic barriers and cultural norms may hinder access to both physical and mental healthcare services. Studies conducted in diverse settings could reveal significant variations in how socioeconomic and cultural factors influence diabetes and suicide outcomes. Such insights underscore the need for context-specific interventions to address systemic disparities and cultural sensitivities, ultimately improving the overall well-being of individuals living with diabetes across different regions and populations.

The elevated risk of suicide among individuals with diabetes highlights the critical need for routine and systematic mental health screening within diabetes care settings. Mental health assessments should become a standard component of diabetes management, recognising the strong bidirectional relationship between psychological well-being and glycemic control. Evidence-based screening tools, such as the Patient Health Questionnaire-9 (PHQ-9) (Manea, Gilbody, and McMillan 2015; Richardson et al. 2010), are well-suited for this purpose, as they are validated for identifying depression and associated suicidal ideation in diverse populations. Implementing such tools in routine clinical practice could facilitate the early detection of psychological distress, allowing for timely intervention and potentially reducing the risk of severe mental health outcomes, including suicide. However, the effective use of these tools requires well-trained healthcare providers who are equipped to interpret results and initiate appropriate responses. Training programs for endocrinologists, primary care physicians, nurses and other healthcare professionals should emphasise the importance of recognising psychological distress in patients with diabetes. Beyond screening, these programs must also address referral pathways and collaborative care approaches to ensure that patients receive integrated physical and mental health support. Additionally, healthcare systems must prioritise the establishment of multidisciplinary care models that embed mental health professionals, such as psychologists or psychiatrists, within diabetes care teams. This integrated approach ensures that both the psychological and physical aspects of diabetes are addressed simultaneously, improving overall outcomes. By adopting such practices, healthcare providers can significantly mitigate the psychological burden associated with diabetes and help reduce the incidence of suicide in this vulnerable population. Future research should explore the implementation and effectiveness of these strategies in diverse clinical and cultural settings.

At the policy level, it is imperative that governments and healthcare systems prioritise the allocation of resources to address the mental health needs of individuals with chronic diseases, including diabetes. This requires a multi-pronged approach to ensure comprehensive and sustainable solutions. Funding should be directed towards the development and implementation of integrated care models that combine diabetes management with mental health services. Such models facilitate the early identification and treatment of psychological conditions, reducing the risk of adverse outcomes, including suicide, while improving overall quality of life. Public awareness campaigns are equally critical and should aim to dismantle the stigma surrounding both diabetes and mental health. Educational initiatives targeting communities, patients and healthcare professionals can foster a more supportive environment and encourage individuals to seek help without fear of judgement. These campaigns should be culturally sensitive and tailored to address specific societal attitudes that may perpetuate stigma and discrimination. Research funding is also essential to develop and evaluate targeted interventions for mental health support in diabetes care. Studies exploring the efficacy of culturally relevant, evidence-based strategies will help ensure that interventions are effective across diverse populations and healthcare systems. Additionally, policies must address systemic inequities by ensuring equitable access to diabetes and mental health services, particularly for marginalised and underserved populations. This includes improving affordability, availability and accessibility of care, as well as addressing social determinants of health that disproportionately affect vulnerable groups. A cohesive policy framework integrating these elements is essential for reducing the burden of mental health challenges in diabetes care.

我们写信是为了表达我们对富有洞察力和全面的系统评价和荟萃分析的深深感谢，“糖尿病患者的自杀死亡、自杀意念和自杀未遂”（Fan 等人，2024 年）作者因解决了严重未被充分探索的心理和身体健康交叉点而受到赞扬，该交叉点具有重大的公共卫生影响。多项研究的数据综合为糖尿病患者自杀行为和意念的风险增加提供了强有力的证据。荟萃分析方法增强了统计能力，并提供了精确的效应量估计，从而使研究结果更有信心。此外，作者按人口统计学和临床因素（例如出版年份、性别和糖尿病类型）进行分层，增加了对可能更容易出现自杀结果的亚组的见解。虽然这项研究揭示了糖尿病与自杀之间的关联，但我们想提供一些反思和考虑，以进一步加深对这一重要话题的讨论。

虽然该研究强调了糖尿病对自杀行为的影响，但证明糖尿病与心理健康之间的双向关系以更好地了解潜在机制至关重要。抑郁症和焦虑症在糖尿病患者中普遍存在（Palizgir、Bakhtiari 和 Esteghamati 2013 年;Woon 等人，2020 年）是自杀意念和行为的公认风险因素。这些心理健康状况可能是由于管理糖尿病的长期压力而引起的，包括血糖监测所需的持续警惕、饮食限制和对长期并发症的恐惧。此外，与糖尿病相关的社会耻辱感，尤其是在年轻人或与生活方式相关的 2 型糖尿病患者中，可能会加剧孤立感和心理困扰。同时，抑郁和焦虑的存在会通过减少对处方方案的依从性，包括药物治疗、生活方式改变和随访预约，对糖尿病管理产生有害影响。心理健康状况不佳也可能通过生理途径加剧血糖控制，例如由于慢性压力导致皮质醇水平升高，这会干扰胰岛素敏感性。这些互动造成了一个恶性循环，其中心理健康状况不佳会使糖尿病结果恶化，这反过来又增加了心理负担和自杀念头或企图的风险。更清楚地描述糖尿病和心理健康之间的这种复杂相互作用可以为整体、综合护理模式的发展提供信息。 这种模式将优先考虑身体和心理健康，利用多学科团队来解决糖尿病患者的全部需求。未来的研究应该纵向探索这些双向动态，以指导有针对性的干预措施和政策举措。

对可能介导糖尿病与自杀之间关联的社会经济和文化因素的更详细探索可能会使荟萃分析受益。社会经济决定因素，例如收入不平等、教育水平、就业状况和医疗保健机会，可以显着影响糖尿病患者的身心健康结果。难以获得负担得起的医疗保健可能会延迟糖尿病的诊断和管理，导致更严重的并发症和加剧的心理困扰，这可能会增加自杀意念或行为的风险。此外，与糖尿病护理的高成本相关的经济压力，尤其是对于胰岛素依赖患者，会加剧心理健康挑战，进一步增加受影响个体的脆弱性。文化耻辱感在塑造这些结果方面也起着关键作用。在许多社会中，糖尿病被视为一种与不良生活方式选择有关的疾病，导致被诊断出的人受到责备和羞耻。当涉及精神疾病时，这种耻辱感会加剧，造成双层社会孤立，并阻止个人为这两种情况寻求帮助。在高收入国家，患者可能有更多机会获得纳入糖尿病护理的心理健康支持，而在低收入和中等收入国家，系统性障碍和文化规范可能会阻碍获得身心保健服务。在不同环境中进行的研究可以揭示社会经济和文化因素如何影响糖尿病和自杀结果的显着差异。 这些见解强调了针对具体情况的干预措施的必要性，以解决系统性差异和文化敏感性，最终改善不同地区和人群糖尿病患者的整体健康状况。

糖尿病患者自杀风险升高凸显了在糖尿病护理环境中进行常规和系统心理健康筛查的迫切需求。心理健康评估应成为糖尿病管理的标准组成部分，认识到心理健康和血糖控制之间有很强的双向关系。循证筛查工具，例如患者健康问卷 9 （PHQ-9） （Manea， Gilbody， and McMillan 2015;Richardson 等人，2010 年），非常适合此目的，因为它们已被验证可用于识别不同人群中的抑郁症和相关自杀意念。在常规临床实践中实施此类工具有助于及早发现心理困扰，从而及时干预并可能降低严重心理健康后果（包括自杀）的风险。然而，有效使用这些工具需要训练有素的医疗保健提供者，他们有能力解释结果并启动适当的响应。针对内分泌科医生、初级保健医生、护士和其他医疗保健专业人员的培训计划应强调认识到糖尿病患者心理困扰的重要性。除了筛查之外，这些计划还必须解决转诊途径和协作护理方法，以确保患者获得综合的身心健康支持。此外，医疗保健系统必须优先建立多学科护理模式，将心理健康专业人员（如心理学家或精神科医生）纳入糖尿病护理团队。 这种综合方法确保同时解决糖尿病的心理和身体方面，从而改善整体结果。通过采用这种做法，医疗保健提供者可以显着减轻与糖尿病相关的心理负担，并帮助降低这一弱势群体的自杀率。未来的研究应探索这些策略在不同临床和文化环境中的实施和有效性。

在政策层面，政府和医疗保健系统必须优先考虑资源分配，以满足包括糖尿病在内的慢性病患者的心理健康需求。这需要多管齐下的方法，以确保全面和可持续的解决方案。资金应用于开发和实施将糖尿病管理与心理健康服务相结合的综合护理模式。这种模型有助于心理状况的早期识别和治疗，降低包括自杀在内的不良后果的风险，同时提高整体生活质量。公众意识运动同样重要，应旨在消除围绕糖尿病和心理健康的耻辱感。针对社区、患者和医疗保健专业人员的教育计划可以营造一个更具支持性的环境，并鼓励个人寻求帮助而不必担心被评判。这些活动应该具有文化敏感性，并针对可能使污名和歧视长期存在的特定社会态度进行定制。研究资金对于开发和评估糖尿病护理中心理健康支持的针对性干预措施也至关重要。探索与文化相关的循证策略的有效性的研究将有助于确保干预措施对不同的人群和医疗保健系统有效。此外，政策必须通过确保公平获得糖尿病和心理健康服务来解决系统性不平等问题，特别是对于边缘化和服务不足的人群。这包括提高护理的可负担性、可及性和可及性，以及解决对弱势群体影响不成比例的健康社会决定因素。 整合这些要素的有凝聚力的政策框架对于减轻糖尿病护理中心理健康挑战的负担至关重要。