Associations between stress symptoms and insomnia in patients with type 2 diabetes: the potential serial mediating roles of anxiety and depressive symptoms

Associations between stress symptoms and insomnia in patients with type 2 diabetes: the potential serial mediating roles of anxiety and depressive symptoms | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 12 January 2026 V1 Latest version Share on Associations between stress symptoms and insomnia in patients with type 2 diabetes: the potential serial mediating roles of anxiety and depressive symptoms Authors : Xi Zhang , Yun Zhang , Yating Yang , Jianyong Zhao , Jingfang Jia , Suqi Song , and Huanzhong Liu [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.176819955.57140609/v1 207 views 76 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Purpose: This study aimed to explore the potential mediating roles of anxiety and depressive symptoms in the association between stress symptoms and insomnia in adults with type 2 diabetes (T2D). Patients and methods: From January 2021 to March 2024, 484 adults with T2D were included. The Depression Anxiety Stress Scale (DASS-21) and Insomnia Severity Index scale (ISI) were used to assess stress symptoms, anxiety symptoms, depressive symptoms, and insomnia. The PROCESS macro program was used to analyze the potential serial mediation pathways. Results: Of the 484 patients, 85 (17.56%) had insomnia. Insomnia patients had significantly higher age, body mass index (BMI), educational level, duration of illness, complication rate, and levels of anxiety symptoms, depressive symptoms, and stress symptoms than the non-insomnia. Correlation analyses showed that insomnia positively correlated with age, duration of illness, stress symptoms, anxiety symptoms, and depressive symptoms, while negatively correlated with educational level (all P < 0.05). Additionally, these four factors were significantly intercorrelated (all P < 0.05). Mediation analyses showed that stress symptoms were directly associated with insomnia (Effect = 0.264, SE = 0.040, 95% CI = 0.137 - 0.295) and indirectly associated via anxiety symptoms (Effect = 0.094, SE = 0.030, 95% CI = 0.035 - 0.156), depressive symptoms (Effect = 0.055, SE = 0.024, 95% CI = 0.010 - 0.104), and the serial pathway through anxiety and depressive symptoms (Effect = 0.026, SE = 0.013, 95% CI = 0.004 - 0.054). Conclusion: In T2D patients, stress symptoms are directly associated with insomnia, and may also be linked to it through anxiety and depression. This study highlights the need to consider these interrelated factors in clinical management to potentially improve sleep and overall health. Introduction Diabetes is a severe and complex chronic illness, and its global prevalence is increasing steadily [1] . Type 2 diabetes (T2D), a primary category of diabetes, accounted for a global prevalence of approximately 438 million people as of 2019 [2] . A meta-analysis showed that the co-morbidity rate of insomnia in T2D patients was as high as 39%, markedly increased in contrast to the general population [3] . Chronic insomnia in T2D patients not only significantly reduces quality of life and interferes with glycemic control and prognosis, but also negatively impacts psychological well-being, potentially leading to loss of treatment confidence [4,5] . Stress symptoms, reflecting one’s subjective appraisal of environmental demands, often triggers psychological stress responses [6] , and is associated with sleep disturbances, such as reduced slow-wave sleep, which may contribute to insomnia [7] . Therefore, exploring the interrelationships among stress symptoms, anxiety symptoms, depressive symptoms, and insomnia in patients with T2D is clinically important. Anxiety and depression, as common mental health problems in today’ s society [8] , are about twice as prevalent in the T2D patient population as in the general population [9] . Another study revealed that among patients with T2D, the prevalence of anxiety reached 51.5%, while depression was present in 37.5% [10] . These emotional problems not only aggravate psychological distress [11,12] , but also associated with disruptions in sleep structure and quality, which are implicated in insomnia [13] . For example, a cross-sectional study in the United States found that individuals with insomnia had much higher anxiety and depression scores compared to those without insomnia [14] . Results of a national survey in South Korea showed a significant association between anxiety and depressive symptoms on the severity of insomnia [15] . In addition, previous research has shown that individuals’ perceived stress levels are strongly associated with their anxiety and depressive symptoms [16,17] . Meanwhile, Zhang and colleagues showed a significant positive correlation between anxiety and depression in diabetic patients through a cross-sectional study [18] . These problems are intertwined, potentially forming a complex interplay that seriously affects patients’ quality of life and disease prognosis. Therefore, it is particularly important to clarify the interrelationships and potential pathways linking stress symptoms, anxiety symptoms, and depressive symptoms to insomnia in patients with T2D. However, the relationships between stress symptoms and insomnia in T2D patients remain underexplored, with less attention paid to potential serial mediating roles of anxiety and depressive symptoms. Clarifying these complex associations may help inform future research on integrated interventions targeting stress, emotion, and sleep in this population. This study used serial mediation analysis to explore these pathways in patients with T2D. Based on the above, this study hypothesized that (1) stress symptoms are directly associated with insomnia in patients with T2D, and (2) anxiety and depressive symptoms may play independent and serial mediating roles in this association. Material and Methods Participants From January 2021 to March 2024, a total of 500 adult patients with T2D were recruited into our study at Chaohu Hospital of Anhui Medical University. Inclusion criteria: (1) Patients aged 18 to 60, regardless of gender; (2) Meet the 2019 World Health Organization (WHO) diagnostic criteria for T2D [19] : fasting blood glucose ≥ 7.0 mmol/L (126 mg/dL), 2-hour post-load glucose ≥ 11.1 mmol/L (200 mg/dL), random blood glucose ≥ 11.1 mmol/L (200 mg/dL) with diabetes symptoms (e.g., polyuria, polydipsia, unexplained weight loss), glycosylated hemoglobin (HbA1c) ≥ 6.5% (48 mmol/mol); (3) Patients fully understood the purpose of the study and were agreeable to cooperating with the evaluation. Exclusion criteria: (1) Comorbid serious mental illnesses such as bipolar disorder and schizophrenia; (2) Presence of other primary sleep disorders, such as sleep narcolepsy and apnea syndrome; (3) Taking medications known to significantly affect sleep, mood, or the central nervous system in the last month (e.g., hypnotics, antidepressants, anxiolytics, corticosteroids, beta-blockers); (4) Combination of severe diabetic complications, such as diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome; (5) Presence of serious infections, neurological diseases, or other severe physical illnesses. Prior to the study, all participants received comprehensive details about the study and provided their consent by signing a form. This study was reviewed and approved by the Ethics Committee of Chaohu Hospital, Anhui Medical University (approval number: No.KYXM-202403-002). In addition, all procedures were conducted in accordance with the ethical standards of the 2013 Helsinki Declaration (https://www.wma.net/policies-post/wma-declaration-of-helsinki/). Measuring instruments Demographic and clinical characteristics We collected information on the demographic characteristics of all participants, including age (years), sex (male / female), body mass index (BMI) (kg/m 2 ), grade (junior high school / senior high school), educational level (years), duration of illness (years), complication (no / yes), hypertension (no / yes), and metformin treatment (no / yes). The Insomnia Severity Index Scale (ISI） The ISI is a simple self-assessment scale used to evaluate the severity of insomnia in the past 2 weeks [20] . This scale consists of 7 items, each rated on a 5-point system ranging from ‘0 = none’ to ‘4 = very severe’. The total scores of this scale is 0-28 points and the total scores of ≥ 8 points indicates the presence of insomnia, with higher scores representing more severe insomnia symptoms [21] . The Depression Anxiety Stress Scale (DASS-21) The DASS-21 is a 21-item self-report scale that evaluates stress symptoms, anxiety symptoms, and depressive symptoms in the past week. The scale uses a 4-point rating system ranging from “0 = does not meet” to “3 = always meets” and consists of 3 subscales for stress symptoms, anxiety symptoms, and depressive symptoms, each with 7 items [22] . The subscale scores are figured by multiplying the total scores for each subscale by 2. Each subscale score spans from 0 to 42, with the total score ranging from 0 to 126. According to the scale’ s rating criteria, a scores of ≥14 on the stress symptoms subscale indicates the presence of stress; a scores of ≥8 on the anxiety symptoms subscale indicates the presence of anxiety; and a scores of ≥10 on the depressive symptoms subscale indicates the presence of depression [23] . Statistical analysis Due to incomplete self-administered questionnaires, complete data from 484 patients were included in the statistical analysis. The analysis was conducted using SPSS version 23.0. The normality of continuous variables was evaluated using the Kolmogorov-Smirnov test. Continuous variables were reported as mean ± standard deviation (SD) or median (quartiles) [M (P25, P75)], while categorical variables were reported as percentages (%). For univariate analyses, various statistical tests were employed to compare differences between groups with and without insomnia symptoms across all variables. These tests included independent samples t-tests, Mann-Whitney U-tests, and chi-square tests. The PROCESS macro program was employed to perform correlation matrix analyses, multiple regression analyses, and serial mediation analyses. Additionally, patients’ age, education level, and duration of illness were controlled for. The confidence interval (CI) was set at 95%, with 5000 bootstrap iterations. A statistically significant difference was defined as P < 0.05 (two-tailed). Demographic and clinical characteristics of patients with T2D Of the 484 patients with T2D included in this study, 85 (17.56%) had insomnia. Regarding demographic characteristics, the ratio of male patients to female patients was 199 / 285, mean age was (44.03 ± 10.07) years, BMI was (25.04 ± 4.14) kg/m 2 , mean educational level was (9.88 ± 4.28) years, and mean duration of illness was (5.26 ± 5.20) years. In addition, the number of patients with complications was 118 (24.38%), hypertension was 62 (12.81%), and metformin treatment was 170 (35.12%). The results of the analyses of differences between the groups showed that age, BMI, educational level, duration of illness, complication rate, anxiety symptoms, depressive symptoms, and stress symptoms were significantly higher in the insomnia group than in the non-insomnia group (all P 0.05). (Table 1). Correlation matrices of variables Correlation matrix analyses showed that ISI scores positively correlated with age (r=0.161, P <0.001), duration of illness (r = 0.140, P < 0.01), stress symptoms (r = 0.340, P < 0.001), anxiety symptoms (r = 0.376, P < 0.001), and depressive symptoms (r = 0.285, P < 0.001), while negatively correlated with educational level (r = -0.091, P < 0.05). Furthermore, stress symptoms, anxiety symptoms, depressive symptoms, and insomnia were all significantly positively correlated with each other (all P < 0.05). (Table 2). Analyses of serial mediation pathways Multiple regression analyses showed that stress symptoms were significantly associated with insomnia ( β = 0.439, t = 10.867, 95% CI = 0.294 - 0.424, P < 0.001). Additionally, stress symptoms were significantly associated with both anxiety symptoms ( β = 0.519, t = 13.512, 95% CI = 0.256 - 0.343, P < 0.001) and depressive symptoms ( β = 0.363, t = 8.262, 95% CI = 0.150 - 0.243, P < 0.001). Anxiety symptoms were also significantly associated with depressive symptoms ( β = 0.323, t = 7.341, 95% CI = 0.224 - 0.388, P < 0.001). The association between stress symptoms and insomnia remained significant when anxiety and depressive symptoms were included as mediating variables ( β = 0.264, t = 5.386, 95% CI = 0.137 - 0.295, P < 0.001). Anxiety symptoms ( β = 0.180, t = 3.674, 95% CI = 0.119 - 0.391, P < 0.001) and depressive symptoms ( β = 0.152, t = 3.179, 95% CI = 0.088 - 0.371, P < 0.01) were also independently associated with insomnia. The significance of all mediation paths supported a serial mediation model. (Table 3). The mediating path was further tested and the results are shown in Table 4. Analyses of total indirect effects indicated that anxiety and depressive symptoms partially mediated the association between stress symptoms and insomnia (Effect = 0.175, SE = 0.044, 95% CI = 0.090 - 0.263). The total indirect effect accounted for 39.86% of the total mediation effect (Effect = 0.439, SE = 0.033, 95% CI = 0.249 - 0.424). When tested individually, the indirect effects of all 3 pathways were significant. Pathway 1: Indirect effect of stress symptoms on insomnia via anxiety symptoms (Effect = 0.094, SE = 0.030, 95% CI = 0.035 - 0.156), accounting for 21.41% of the total effect; Pathway 2: Indirect effect of stress symptoms on insomnia via depressive symptoms (Effect = 0.055, SE = 0.024, 95% CI = 0.010 - 0.104), accounting for 12.53% of the total effect; Pathway 3: Indirect effect of stress symptoms on insomnia via anxiety symptoms and then depressive symptoms (Effect = 0.026, SE = 0.013, 95% CI = 0.004 - 0.054), accounting for 5.92% of the total effect. The specific path was shown in Fig. 1. Discussion Our study examined a serial mediation model in adult patients with T2D. The main objective was to examine the associations between stress symptoms and insomnia, and the potential mediating roles of anxiety and depressive symptoms. In our study, the prevalence of insomnia in patients with T2D was 17.56%, which is higher than in a recent French cohort study (7.5%) [24] , but slightly lower than in another Chinese cross-sectional study (24.16%) [25] . This variation may be due to a combination of factors, including differences in population characteristics, comorbidities, complications, and emotional status. Given the negative impact of sleep disorders on glycemic management and quality of life in diabetic patients [26,27] , the assessment and management of sleep problems in this population is of clinical importance. Our study found that insomnia severity in patients with T2D were significantly and positively correlated with age and duration of illness, but significantly negatively correlated with educational level. First, age has been demonstrated to be associated with insomnia [28] . A large U.S. cohort study showed that among patients with T2D, the mean age of those with insomnia was significantly greater than that of those without insomnia [29] . Additionally, a recent meta-analysis suggested that the absolute incidence of sleep disorders over 5 years was significantly greater in middle-aged and older individuals with T2D than in younger individuals with the same condition [30] . On the one hand, this may be related to the decrease in nocturnal production of melatonin due to aging [31] . On the other hand, a rise in the frequency of sleep awakenings and a decrease in sleep depth with age are factors associated with insomnia [32] . Secondly, a study found that patients with T2D who who suffered from sleep disorders had significantly longer duration of illness than those without [33,34] . As diabetes duration increases, patients face long-term disease-related challenges, which may be associated with increased psychological stress and, concurrently, more severe insomnia [35] . Finally, no studies have directly confirmed the negative correlation between educational attainment and the severity of insomnia in patients with T2D. However, existing research suggests that individuals with lower levels of education may be more likely to experience insomnia [36] . Thus, among patients with T2D, individuals with less education may experience greater stress due to inadequate disease knowledge and management, which may be related to insomnia. In addition, this study showed that stress symptoms, anxiety symptoms, depressive symptoms, and insomnia were all significantly positively correlated with each other in patients with T2D. Specifically, stress symptoms were strongly related to levels of anxiety and depressive symptoms, consistent with previous findings [37-39] . Stress symptoms may be linked to imbalanced blood glucose regulation and low treatment adherence, and elevated blood glucose levels are also associated with negative feelings such as anxiety and depression [40] . Second, anxiety symptoms were also strongly associated with the severity of depressive symptoms, further highlighting the interplay between psychological factors. McInerney et al. demonstrated that anxiety symptoms are strongly associated with depressive symptoms in diabetic patients through network analysis [41] . This may correspond to the feelings of despair that arise when individuals repeatedly fail to control their anxiety [42] . Finally, stress symptoms, anxiety symptoms, and depressive symptoms were all strongly associated with insomnia severity, indicating that these factors are closely linked to sleep quality. A cross-sectional study from Malaysia suggests that stress, anxiety, and depressive symptoms are all independent correlates of poor sleep quality in patients with T2D [43] . Stress, anxiety, and depression are often accompanied by poor sleep hygiene behaviors, such as excessive use of electronic devices [44] . And there is a significant positive correlation between electronic information overload and insomnia [45] . Additionally, blood glucose fluctuations, including hyperglycemic and hypoglycemic events, can disrupt sleep continuity and are linked to worse insomnia [46] . All of the above studies highlight the important role of psychological factors in the course of T2D. Therefore, clinical interventions that integrate stress management and emotional regulation may hold promise for improving sleep in T2D patients, which could be evaluated in future interventional studies. We also found that anxiety and depressive symptoms may play not only independent but also serial mediating roles in the association between stress symptoms and insomnia in patients with T2D. First, stress symptoms is linked to insomnia via its association with anxiety or depressive symptoms, consistent with previous findings [47-49] . For example, a longitudinal study found a significant positive relationship between stress symptoms and insomnia, which could be partially mediated by anxious or depressive moods [47] . Theoretically, stress may impair signaling in the body’ s glucocorticoid and mineralocorticoid receptor systems [50] , affecting neurotransmitter homeostasis and neurological functioning, which in turn may be related to the development of anxiety and depressive symptoms [51,52] . These emotional states, associated with hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis [53] , can promote elevated cortisol levels that may disrupt sleep [54] . Additionally, stress-related anxiety and depression may be accompanied by negative cognitive patterns like rumination, which are also related to insomnia [55] . Together, these lines of evidence provide a theoretical basis for the observed associations in our study. Second, our finding of a serial pathway (stress → anxiety → depression → insomnia) aligns with the conceptual model that perceived stress may be linked to anxiety symptoms, which in turn are closely associated with depressive symptoms [56] , and their co-occurrence is strongly correlated with worse insomnia [57] . The potential mechanisms underlying these associations are complex. Stress is thought to affect brain regions involved in emotion regulation (e.g., prefrontal-amygdala circuitry) [58] , potentially contributing to anxiety [59] . Anxiety may stimulate inflammatory responses [60] , and inflammatory factors can interfere with tryptophan metabolism, a pathway implicated in depression [61] . In patients with T2D, a hyperglycemic state might exacerbate these processes [62] . While our cross-sectional data cannot test these mechanistic pathways, the observed serial associations are congruent with such a theoretical framework. Our study examined a serial mediation model, revealing significant indirect associations linking stress symptoms to insomnia through anxiety and depression in T2D patients. This highlights the potential clinical value of considering psychological evaluation and exploring integrated interventions targeting stress and emotional distress, which may contribute to improving sleep and overall health in this population. There were some limitations to this study. First and foremost, the cross-sectional design precludes causal inferences and cannot verify the temporal sequence implied by the serial mediation model (e.g., that stress symptoms precede anxiety, which in turn precedes depressive symptoms, and ultimately insomnia). Secondly, reliance on self-report measures (ISI and DASS-21) may introduce common method bias and reporting inaccuracies; the lack of objective sleep measurements (e.g., actigraphy) and clinical interviews limits the depth of assessment. Third, despite controlling for several demographic and clinical variables, residual confounding may persist due to unmeasured or insufficiently controlled factors, such as detailed glycemic control (HbA1c trajectories), specific medications affecting sleep/mood, and the differential impact of specific diabetic complications (e.g., neuropathic pain). Finally, the single-center sample may also limit the generalizability of the results. Future research should employ longitudinal or experimental designs to establish temporal precedence and causal relationships. Incorporating objective measures of sleep and stress physiology, along with more comprehensive assessment of medical confounders, is essential. Multicenter studies with larger, more diverse samples are needed to enhance generalizability and allow for robust subgroup analyses. Conclusion This study demonstrated a significant association between stress symptoms and insomnia in patients with T2D. Anxiety and depressive symptoms were found to play significant independent and serial mediating roles in this association, even after accounting for factors like age, educational level, and duration of illness. These findings suggest that in the clinical management of T2D patients, it is important to consider the interrelationship among stress symptoms, emotional distress, and sleep problems. Future research using longitudinal or interventional designs is needed to clarify the causal directions and to evaluate the efficacy of integrated interventions aimed at improving sleep and psychological health in this population. Acknowledgements We sincerely thank all the study participants. Funding Statement This study was supported by Anhui Health Research Project (Grant No. AHWJ2024Aa10004) and Guangdong Basic and Applied Basic Research Foundation Joint Fund (Grant No. 2024A1515110265). Data Sharing Statement The data used for this study are available from the corresponding author ( [email protected] ) on reasonable request. Ethics Approval and Informed Consent This study was reviewed and approved by the Ethics Committee of Chaohu Hospital, Anhui Medical University (approval number: No.KYXM-202403-002). Prior to the study, all enrolled participants were provided with detailed information about the purpose and content of the study, and both they and their guardians provided written informed consent. Author contributions HL and SS: the study’s design. XZ, YZ, YY, JZ, and JJ: collection, analyses and interpretation of the data. XZ: drafting of the manuscript. HL and SS: revision of the manuscript. The final version of the publication was approved by all authors. 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Variables Total sample (n = 484) Insomnia group (n = 85) Non-insomnia group (n = 399) t / Z / χ 2 P Demographic characteristics Age (years), mean (SD) 44.03 (10.07) 49.45 (10.93) 42.88 (9.50) 5.631 <0.001 Male, n (%) 199 (41.12) 54 (63.53) 285 (71.43) -2.084 0.149 BMI (kg/m 2 ), mean (SD) 25.04 (4.14) 24.30 (4.18) 25.20 (4.11) -2.497 0.013 Educational level (years), mean (SD) 9.88 (4.28) 8.96 (4.56) 10.08 (4.20) -2.178 0.030 Duration of illness (years), median (P 25 , P 75 ) 4.00 (2.00, 7.00) 5.00 (3.00, 11.50) 3.00 (2.00, 5.00) 4.641 a <0.001 Complication, n (%) 118 (24.38) 29 (34.12) 89 (22.31) 5.303 0.021 Hypertension, n (%) 62 (12.81) 12 (14.12) 50 (12.53) 0.158 0.691 Metformin treatment, n (%) 170 (35.12) 25 (29.41) 145 (36.34) 1.476 0.224 Clinical characteristics DASS-21 scale Stress symptoms scores, median (P 25 , P 75 ) 4.00 (2.00, 8.00) 8.00 (4.00, 15.00) 4.00 (2.00, 6.00) 7.211 a <0.001 Anxiety symptoms scores, median (P 25 , P 75 ) 2.00 (0.00, 4.00) 6.00 (2.00, 8.00) 2.00 (0.00, 4.00) 7.292 a <0.001 Depressive symptoms scores, median (P 25 , P 75 ) 0.00 (0.00, 2.00) 2.00 (0.00, 6.00) 0.00 (0.00, 2.00) 5.980 a <0.001 BMI, body mass index; DASS-21, The Depression Anxiety Stress Scale; ISI Scale, Insomnia Severity Index Scale. a Mann-Whitney U test. Table 2 Correlation matrices of variables (N = 484). Variables 1 2 3 4 5 6 7 8 9 10 11 12 Age 1.000 — — — — — — — — — — — Gender -0.045 1.000 — — — — — — — — — — BMI -0.186 *** 0.054 1.000 — — — — — — — — — Educational level -0.357 *** 0.278 *** 0.125 ** 1.000 — — — — — — — — Duration of illness 0.400 *** -0.072 -0.129 ** -0.180 *** 1.000 — — — — — — — Complication 0.131 ** -0.080 -0.162 *** -0.110 * 0.183 *** 1.000 — — — — — — Hypertension 0.130 ** 0.021 0.160 *** -0.029 -0.008 0.070 1.000 — — — — — Metformin treatment -0.087 0.047 -0.083 0.001 0.010 -0.065 -0.088 1.000 — — — — Stress symptoms 0.131 ** -0.132 ** -0.077 -0.155 ** 0.085 0.113 * 0.047 0.006 1.000 — — — Anxiety symptoms 0.215 *** -0.028 -0.004 -0.104 * 0.157 ** 0.195 *** 0.049 -0.050 0.422 *** 1.000 — — Depressive symptoms -0.145 ** -0.036 -0.049 0.054 0.021 0.108 * 0.007 -0.026 0.459 *** 0.311 *** 1.000 — ISI scores 0.161 *** -0.048 -0.058 -0.091 * 0.140 ** 0.068 0.039 -0.032 0.340 *** 0.376 *** 0.285 *** 1.000 *, p < 0.05; **, p < 0.01; ***, p < 0.001; —, Duplicate data, no longer listed; BMI, body mass index. Table 3 Regression analysis between variables ( N = 484). Dependent variables Predictive variables R R 2 F β t 95% CI Insomnia Age 0.512 0.262 42.469 *** 0.135 3.056 ** [0.021, 0.097] Educational level 0.008 0.201 [-0.076, 0.094] Duration of illness 0.094 2.191 * [0.008, 0.152] Stress symptoms 0.439 10.867 *** [0.294, 0.424] Anxiety symptoms Age 0.576 0.332 59.434 *** 0.168 4.004 *** [0.027, 0.078] Educational level 0.067 1.676 [-0.008, 0.106] Duration of illness 0.055 1.338 [-0.015, 0.081] Stress symptoms 0.519 13.512 *** [0.256, 0.343] Depressive symptoms Age 0.606 0.368 55.566 *** -0.157 -3.774 *** [-0.069, -0.022] Educational level 0.101 2.594 ** [0.017, 0.121] Duration of illness 0.078 1.959 [0.000, 0.088] Stress symptoms 0.363 8.262 *** [0.150, 0.243] Anxiety symptoms 0.323 7.341 *** [0.224, 0.388] Insomnia Age 0.558 0.312 35.991 *** 0.120 2.726 ** [0.015, 0.091] Educational level -0.022 -0.544 [-0.106, 0.060] Duration of illness 0.070 1.666 [-0.011, 0.129] Stress symptoms 0.264 5.386 *** [0.137, 0.295] Anxiety symptoms 0.180 3.674 *** [0.119, 0.391] Depressive symptoms 0.152 3.179 ** [0.088, 0.371] *, p < 0.05; **, p < 0.01; ***, p < 0.001. Table 4 Indirect effect of Stress symptoms on insomnia via anxiety and depression symptoms (N = 484). Effect SE 95% CI Effect size (%) Total effect 0.439 0.033 [0.294, 0.424] 100.00 Direct effect 0.264 0.040 [0.137, 0.295] 60.14 Total indirect effect 0.175 0.044 [0.090, 0.263] 39.86 Indirect path 1 0.094 0.030 [0.035, 0.156] 21.41 Indirect path 2 0.055 0.024 [0.010, 0.104] 12.53 Indirect path 3 0.026 0.013 [0.004, 0.054] 5.92 Indirect path 1: Stress symptoms → Anxiety symptoms → Insomnia Indirect path 2: Stress symptoms → Depressive symptoms → Insomnia Indirect path 3: Stress symptoms → Anxiety symptoms → Depressive symptoms → Insomnia Figure 1 The serial mediation model of anxiety symptoms and depressive symptoms between stress symptoms and insomnia. *, p < 0.05; **, p < 0.01; ***, p < 0.001. The number in brackets represents the coefficient on the direct path before adding the mediation variable. Information & Authors Information Version history V1 Version 1 12 January 2026 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords anxiety symptoms depressive symptoms insomnia stress symptoms type 2 diabetes Authors Affiliations Xi Zhang Chaohu Hospital of Anhui Medical University View all articles by this author Yun Zhang Chaohu Hospital of Anhui Medical University View all articles by this author Yating Yang Second People's Hospital of Huizhou View all articles by this author Jianyong Zhao Chaohu Hospital of Anhui Medical University View all articles by this author Jingfang Jia Chaohu Hospital of Anhui Medical University View all articles by this author Suqi Song Chaohu Hospital of Anhui Medical University View all articles by this author Huanzhong Liu [email protected] Chaohu Hospital of Anhui Medical University View all articles by this author Metrics & Citations Metrics Article Usage 207 views 76 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Xi Zhang, Yun Zhang, Yating Yang, et al. 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