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Behav. Sci. 2022, 12, 423. https://doi.org/10.3390/bs12110423 www.mdpi.com/journal/behavsci
Review
Traditional Chinese Medicine Body Constitutions as Predictors
for Depression: A Systematic Review and Meta-Analysis
Sin Yee Yap 1, Foong Leng Ng 1,2, Menaga Subramaniam 1, Yang Mooi Lim 1,3 and Chai Nien Foo 1,4,*
1 Centre for Cancer Research, M. Kandiah Faculty of Medicine and Health Sciences, Universiti Tunku Abdul
Rahman, PT21144, Jalan Sungai Long, Bandar Sungai Long, Kajang 43000, Selangor, Malaysia
2 Department of Traditional Chinese Medicine, M. Kandiah Faculty of Medicine and Health Sciences,
Universiti Tunku Abdul Rahman, PT21144, Jalan Sungai Long, Bandar Sungai Long,
Kajang 43000, Selangor, Malaysia
3 Department of Pre-Clinical Science, M. Kandiah Faculty of Medicine and Health Sciences, Universiti Tunku
Abdul Rahman, Lot PT21144, Jalan Sungai Long, Bandar Sungai Long, Kajang 43000, Selangor, Malaysia
4 Department of Population Medicine, M. Kandiah Faculty of Medicine and Health Sciences, Universiti Tunku
Abdul Rahman, PT21144, Jalan Sungai Long, Bandar Sungai Long, Kajang 43000, Selangor, Malaysia
* Correspondence: foocn@utar.edu.my
Abstract: Traditional Chinese medicine body constitution (TCMBC) reflects a person’s vulnerabil-
ity to diseases. Thus, identifying body constitutions prone to depression can help prevent and treat
depression. The review aimed to assess and summarize the existing evidence that explores the re-
lationship between TCMBC and depression. Psychology and Behavioral Sciences Collection,
MEDLINE, PubMed, CNKI, Wanfang, SinoMed, Embase, VIP, CINAHL, and CMJ were searched
from inception to April 2021. Observational studies assessing the association between TCMBC and
depression were selected. The quality of the included studies were assessed using the Newcastle–
Ottawa Scale (NOS). Eighteen studies were included in the systematic review and thirteen in the
meta-analysis. The pooled odd ratios of developing depression for Qi-stagnation, Qi-deficiency,
Yang-deficiency, Yin-deficiency, and Balanced constitutions were 3.12 (95% CI, 1.80–5.40; I2 = 94%),
2.15 (95% CI, 1.54–3.01; I2 = 89%), 1.89 (95% CI, 0.71–5.03; I2 = 81%), 1.41 (95% CI, 0.91–2.20; I2 = 57%),
and 0.60 (95% CI, 0.40–0.90; I2 = 94%), respectively. The findings suggest that the evaluation of a
person’s TCMBC could be useful the in prevention and treatment of depression. However, more
case-control and cohort studies are required to further confirm the association between TCMBC
and depression.
Keywords: traditional Chinese medicine; body constitution; depression; predictor; systematic re-
view; meta-analysis
1. Introduction
Depression is the cancer of the 21st century. It is one of the leading causes of the
overall global burden of disease [1]. As of 2017, about 264 million people suffered from
depression globally, with a higher prevalence in women (4.1%) than men (2.7%) [1]. De-
pression often develops at a young age and is constantly recurring [2]. Depression is not
merely excessive sadness, but rather, a combination of factors related to negative
thoughts, other symptoms and the bodily impact that lead to significant impairments in
how an individual functions in daily life. Depressed individuals are shown to be vul-
nerable to heart diseases [3], diabetes [4], stroke [5] and infectious diseases [6]. Depres-
sion is a significant cause of mortality [7] and an important risk factor for suicide. Ac-
cording to the World Health Organization (WHO), nearly 800,000 people die due to sui-
cide each year, which means that every 40 seconds, a person kills him/herself. Globally,
suicide is the second leading cause of death in children, adolescents and young adults [8].
Citation: Yap, S.Y.; Ng, F.L.;
Subramaniam, M.; Lim, Y.M.; Foo,
C.N. Traditional Chinese Medicine
Body Constitutions as Predictors for
Depression: A Systematic Review
and Meta-Analysis. Behav. Sci. 2022,
12, 423. https://doi.org/10.3390/
bs12110423
Academic Editors: Magdalena Iorga
and Camelia Soponaru
Received: 22 September 2022
Accepted: 27 october 2022
Published: 30 October 2022
Publisher’s Note: MDPI stays neu-
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Copyright: © 2022 by the authors.
Licensee MDPI, Basel, Switzerland.
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Attribution (CC BY) license
(https://creativecommons.org/license
s/by/4.0/).
Behav. Sci. 2022, 12, 423 2 of 22
There are variations in the types of depression and their severities. The most com-
mon type of depression is major depressive disorder (MDD), also known as clinical de-
pression. It is characterized by depressed mood and loss of interest or pleasure [9]. Ac-
cording to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5), at least one of these two symptoms must be present along with another five or
more symptoms for at least two weeks for a person to be diagnosed with MDD. Several
other symptoms include sleeping problems, changes in appetite, constant fatigue, diffi-
culty concentrating, agitation or slowed movement, feeling guilty or worthlessness, un-
explainable pains and suicidal thoughts [9]. Dysthymia, also known as a persistent de-
pressive disorder, is an ongoing and chronic form of depression. Its symptoms are often
less severe than MDD but longer lasting. The essential feature of this disorder is the
presence of a sad mood on most days for at least two years [9]. Besides, some people may
experience seasonal affective disorder (SAD) during fall or winter due to reduced day-
light [9]. SAD usually wears off during Spring and Summer. The main symptoms include
social withdrawal, oversleeping, low energy and weight gain [9]. Another subtype of
depression is bipolar disorder, which also called manic depression. People who suffer
from bipolar disorder can have extreme mood swings from emotional highs to lows [9].
During the low phases, they will experience symptoms of MDD.
Depression is often caused by a combination of various factors, rather than just one
cause. There is a range of contributing factors that can lead to depression. The genes and
traits that one inherits from their parents make them prone to depression [10]. Lack of
social support, troubled relationships or loss of loved ones can also induce suicidal
thoughts and feelings of worthlessness, increasing depression risk [10]. Other risk factors
for depression include stressful life events, childhood trauma, substance use, poor nutri-
tion and lack of exercise [10]. This is consistent with past reviews and meta-analyses that
found social support [11–13], substance use [14], diet [15], physical activity [16] and ex-
posure to early life stress, such as childhood trauma and loss of loved ones [17], were
associated with depression risk. In addition, depression is also a common complication of
other chronic illnesses. For instance, a recent Danish study showed that people who suf-
fered from heart diseases and stroke were more likely to have subsequent depression
[18].
Currently, the screening and diagnosis of depression is mainly based on symptoms.
Psychiatrists diagnose depression according to patients’ descriptions of symptoms,
questionnaires and clinical behaviour observations, and subsequently categorize the pa-
tients according to the DSM-5 [9] and the eleventh revision of International Statistical
Classification of Diseases and Related Health Problems (ICD-11) [19]. There is no labor-
atory test to identify depression due to its heterogeneous nature. The complex interaction
of genetic, biological, psychological and environmental factors that contribute to depres-
sion affects the accuracy of diagnosis, our understanding towards its pathophysiology,
and our ability to develop effective treatments.
Depression is treatable; however, many depressed individuals fail to receive ade-
quate treatment, especially those in low- and middle-income countries [20]. Barriers to
effective care include inaccurate diagnosis, lack of facilities and trained personnel, social
discrimination and high treatment costs [21]. Treatments of depression usually include
medications and psychotherapies. There are several types of antidepressants available,
such as selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs)
and monoamine oxidase inhibitors (MAOIs) [9,22]. However, these drugs may induce a
range of side effects, such as dry mouth, vision problems, dizziness, irritability, bleeding
abnormalities, seizure and constipation [9,22,23]. Psychotherapies are also known as talk
therapies. Examples of psychotherapies are cognitive-behavioral therapy (CBT), inter-
personal therapy (IPT) and problem-solving therapy [9,24]. Past meta-analyses demon-
strated that pharmacotherapy [25,26] and psychotherapy [25,27,28] were associated with
reduced risk of relapse and recurrence in depression.
Behav. Sci. 2022, 12, 423 3 of 22
Traditional Chinese medicine (TCM) is one of the oldest medical systems globally.
An important aspect of TCM is the prevention of diseases by maintaining or restoring the
harmony and equilibrium of Yin-Yang within the human body [29,30]. Illness often oc-
curs due to the imbalance of Yin-Yang. According to TCM theories, the five fundamental
substances (essence, Qi, blood, body fluids and spirit) and the five viscera (liver, spleen,
lung, heart and kidney) are closely related to each other and the formation of body con-
stitution [31]. Biased body constitutions result from the impaired viscera function and
dysregulation of fundamental substances [31]. The concept of Traditional Chinese medi-
cine body constitution (TCMBC) reflects a person’s unique physical, physiological and
psychological functions [32]. It is determined by hereditary and acquired factors in the
process of human life [32]. Pathologically, TCMBC also influences a person’s susceptibil-
ity to certain pathogenic factors and diseases, as well as their reaction to treatment [32]. It
is the foundation for TCM practitioners to diagnose, treat and prevent diseases [33].
TCMBC is alterable due to its relative stability and dynamic variability [34]. A biased
constitution can be modified towards a neutral type through acquired factors such as
exercise and diet. An appropriate amount of physical activity can produce strong mus-
cles and bones, promote the blood circulation and Qi dynamic and enhance visceral
function [32]. This can then prevent the formation of biased constitutions, such as
Blood-stasis (BSC) and Qi-stagnation (QSC). On the contrary, lack of exercise will result
in flabby muscles, restricted flow of Qi and blood and impaired spleen and stomach
function, which can contribute to the formation of a Phlegm-dampness constitution
(PDC) [32]. Furthermore, a healthy diet and sufficient nutrients can produce a strong
physique and good constitution, while an unbalanced diet and malnutrition could lead to
a weaker constitution [32]. Very often, biased and unbalanced constitutions are detected
among depressed populations [35–37]. For example, Chen et al. found that women with
Yang- and Yin-deficient constitutions had a higher risk of depression [35], while Xiong et
al. found that college students with Qi-stagnation and Qi-deficiency constitutions were
more prone to depression [38].
The China Association for Traditional Chinese Medicine classified TCMBC into nine
types, namely the Balanced constitution (BC), Qi-stagnation constitution (QSC), Blood
stasis constitution (BSC), Qi-deficiency constitution (QDC), Yin-deficiency constitution
(YIDC), Yang-deficiency constitution (YADC), Phlegm-dampness (PDC), Damp-heat
constitution (DHC) and Inherited special constitution (ISC) [34]. Among them, BC is a
neutral type, while the rest are biased and unbalanced types. BC is a harmonious con-
stitution, with a balance of Yin-Yang [32,39]. People with this constitution display com-
mon features, such as a normal body shape, strong physique, optimistic personality,
good adaptability, energetic nature and strong immune system [31,32,40]. People with
BC seldom get sick, and if they do, they recover from sickness easily [32]. Generally,
people with QSC often cope poorly with stressful situations. People with this constitution
exhibit a thin physique, mood swings, suspiciousness, overthinking and excessive wor-
rying [31,32,40]. People with BSC usually have dull skin and dark lips, get bruises easily,
are forgetful and are averse to cold environments and weather [31,32,40]. Additionally,
they are prone to body pain and bleeding [31,32]. Next, people with QDC are easily ex-
hausted due to weak immunity [31,32,40]. They are prone to panting and colds, and are
easily affected by sudden climate changes. These people require a longer time to recover
from sickness [31,32]. People with YIDC have warm palms and soles, are impatient and
exhibit an extroverted nature [40]. These people are always thirsty, prefer cold drinks and
dislike hot and dry weather [31,32]. In contrast, people with YADC are usually intro-
verted, quiet, shy and have cold limbs [40]. They prefer hot meals and summer over
winter [31,32]. The main characteristics of PDC include excessive phlegm production,
overweightedness, chest tightness and a mild-mannered and patient nature [31,32,40].
These people like high sugar and high fat food and dislike damp environments [31,32].
People with DHC usually have oily skin, are prone to acne outbreaks, have a bitter taste
in their mouths, and experience difficult and sticky bowel movements [31,32,40]. They
Behav. Sci. 2022, 12, 423 4 of 22
are irritable and averse to hot and humid climates [32]. Lastly, people with ISC often have
an inherent sensitivity to certain allergens, such as pollen, odors, food and medicines
[40]. They tend to have conditions like asthma and are sensitive to environmental
changes [31,32].
Conventionally, TCM practitioners describe the etiologies and symptoms of de-
pression caused by extreme emotional changes using “yu” or “yuzheng”, which means
blockage, stagnation, not flowing, clogging, or obstruction [41]. In TCM, the deficiency of
Qi (vital energy) is believed to be the main cause of depression [42,43]. Qi deficiency
could be due to physiological dysfunctions in the human body, which include inflam-
mation, abnormal blood circulation, formation of dampness or phlegm [43]. Hence,
strengthening the Qi and fixing imbalances of the physiological systems are the princi-
ples for healing depression [44]. In TCM, the liver is in charge of dispersion and dredging
to regulate digestion, absorption and emotions, as well as the circulation of Qi, blood and
body fluids [31,45]. Normally, the liver-Qi is the first to be affected directly during an
emotional change, followed by disharmony of the Qi among the five viscera, which can
then lead to the dysregulation of the Qi and blood [43]. A dysfunction of liver dispersion
and dredging can also lead to the repression of spleen function, followed by the dysreg-
ulation of heart-Qi, then leading to the “shen” (spirit) becoming restless, which can result
in an unstable and depressed mood [43]. This is because our spirit resides in the heart,
and heart-Qi is in charge of pumping blood and the regulation of blood flow within the
human body [31]. Past studies have confirmed this theory, where the abnormal disper-
sion of liver-Qi causes depression [46–51].
Currently, application and research on TCMBCs are mainly performed in Asian
countries, such as China [35–38], Japan [52,53], Hong Kong [54,55], the Philippines [56]
and Malaysia [57]. Identification of TCMBCs that are vulnerable to depression can allow
us to modify them towards harmony and balance. TCMBC has clinical significance in
preventing depression as it can be applied to indicate a person’s overall health conditions
and help prevent depression in the early phase. With the extensive application of TCMBC
in the past decade, a number of studies have revealed that depression is correlated to
TCMBC [58–62]. However, the findings of the associations are inconsistent and lack a
systematic review to clarify the strength of these associations. Only a narrative review
reporting the potential role of TCMBC in the development of depression was published
[63]. Hence, there is a need for a comprehensive review to evaluate the association be-
tween TCMBC and depression. To date, and to our knowledge, this is the first systematic
review and meta-analysis investigating the association between TCMBC and depression.
This systematic review and meta-analysis aims to assess and to summarize the existing
empirical data that explored the relationship between TCMBC and depression. The key
objectives are as follows: (1) to report whether TCMBC is associated with depression; and
(2) to assess whether TCMBC predicts depression. The findings of this review will pro-
vide knowledge and references for developing measures to manage depression.
2. Materials and Methods
The conduct and reporting of this systematic review and meta-analysis were strictly
based on the Preferred Reporting Items for Systematic reviews, and Meta-Analyses
(PRISMA) ([64] and Meta-analysis of Observational Studies in Epidemiology (MOOSE)
[65] guidelines, following an a priori protocol. The study protocol was registered and
published at the International Prospective Register of Systematic Reviews (PROSPERO)
with a registration number of CRD42021267651, and is under review for publication.
Behav. Sci. 2022, 12, 423 5 of 22
2.1. Data Sources and Search Strategy
Comprehensive literature searches were conducted in the following databases:
Psychology and Behavioral Sciences Collection, MEDLINE, PubMed, Chinese National
Knowledge Infrastructure (CNKI), Wanfang, SinoMed, Embase, Chinese Scientific Jour-
nal Database (VIP), Cumulated Indexed to Nursing and Allied Health Literature (CI-
NAHL) and Chinese Medical Journal Database (CMJ). No restriction was set on the pub-
lication date. The database searches were limited to journal articles written in the English
and Chinese languages only. The database searches were conducted from December 2020
to April 2021. The search terms used are presented in Table 1. Additionally, the refer-
ences of the included studies were manually searched to identify other relevant studies.
Table 1. Search terms.
Concept
Search Terms
Depression
depression OR depressive disorder OR yuzheng
TCMBC
traditional Chinese medicine constitution OR traditional
Chinese medicine body constitution
Note: yuzheng refers to depression in traditional Chinese medicine.
2.2. Eligibility Criteria
The main inclusion criteria were related to: (1) study type: observational studies in-
cluding cohort, case-control and cross-sectional studies that investigate the association
between TCMBC and depression; (2) participant: all subjects and populations were con-
sidered; if there was a control group, the subjects should be from the general population
and without depression; (3) outcome: the correlation between TCMBC and depression
were reported; (4) measurement of TCMBC and depression: the identification of TCMBC
and depression through validated instruments. Only articles published in English and
Chinese were included.
The exclusion criteria were as follows: (1) was not a journal article (e.g., conference
abstract, dissertations and reports); (2) was not primary research (e.g., systematic review
and meta-analysis); (3) lacked sufficient information to determine eligibility; (4) involved
non-human subjects; (5) did not explicitly focus on the association between TCMBC and
depression.
2.3. Study Selection
For English databases (Psychology and Behavioral Sciences Collection, MEDLINE,
PubMed, and Embase), two reviewers (SYY and MS) independently conducted the
searches and screened the titles and abstracts of all retrieved articles, followed by the full
text screening of potentially eligible studies. For Chinese databases (CNKI, Wanfang,
SinoMed, VIP, CINAHL, and CMJ), two reviewers (SYY and FLN) independently con-
ducted the searches and screened the titles and abstracts of all retrieved articles, followed
by the full text screening of potentially eligible studies. The full texts were reviewed ac-
cording to predefined inclusion criteria. Disagreements at both screening levels (ti-
tle/abstract and full text) were resolved through discussion and consultation with other
authors (YML and CNF).
2.4. Data Extraction
Three reviewers (SYY, FLN and MS) independently extracted the data from the in-
cluded studies using a standardized data extraction spreadsheet. Disagreements were
resolved through discussion with other authors (YML and CNF). The following data
were extracted: first author, year of publication, study design, study subjects, sampling
method, study location, sample size, age, gender, ethnicity, depression measurement,
TCMBC measurement, type of constitutions studied, main results (e.g., p value, odd ratio
Behav. Sci. 2022, 12, 423 6 of 22
(OR) and 95% confidence interval (CI)). The primary outcome was the association be-
tween TCMBC and depression.
2.5. Missing Data
When encountering missing data, the corresponding authors of the potentially eli-
gible studies were contacted by E-mail to retrieve further data or clarifications. The
studies were excluded and the data synthesis was conducted using available data when
the authors did not respond or failed to provide the relevant data requested within a
month.
2.6. Assessment of Risk of Bias and Certainty of Evidence
Three reviewers (SYY, FLN and MS) independently performed risk of bias assess-
ment using the Newcastle–Ottawa Scale (NOS) [66,67]. The NOS evaluates the quality of
the included studies regarding three main aspects: (1) selection; (2) comparability; (3)
exposure. The maximum scores for case-control and cohort studies are 9 and for
cross-sectional studies are 10. Regarding the quality of the included case-control and
cohort studies, they were considered as poor if the score was 0 to 5 and good if the score
was 6 to 9. For the quality of cross-sectional studies, they were rated as poor if the score
was 0 to 4, medium if the score was 5 to 6, good if the score was 7 to 8 and very good if
the score was 9 to 10. Disagreements in the quality assessment were adjudicated by dis-
cussion with other authors (YML and CNF).
The quality of evidence and the strength of recommendation of this review were
evaluated using the Grading of Recommendations Assessment, Development and Eval-
uation (GRADE) guidelines [68]. Five criteria were considered when decreasing the level
of certainty, including risk of bias, imprecision, inconsistency, indirectness and publica-
tion bias. Whereas, three additional criteria, which included large magnitude of effect,
dose-response gradient, and when residual confounders would decrease the magnitude
of effect (when an effect is observed), were considered when upgrading the level of cer-
tainty. The overall quality can be rated as very low, low, moderate and high. The lowest
quality of evidence for any of the outcomes determine the overall quality of evidence.
2.7. Data Synthesis and Analysis
Data from the eligible studies were summarized descriptively in tabular format and
narrative text. The characteristics of the studies were reported and grouped in the table
based on population types (diseased and general populations). Cochrane Software Re-
view Manager (RevMan), version 5.3 (The Cochrane Collaboration, 2020) was used to
perform statistical analysis if a meta-analysis was allowed. Meta-analyses were per-
formed if there was sufficient number of studies (n ≥ 2), adequate quality of studies
(moderate and good quality) and similarity in the study design. Inverse variance analysis
was used in the meta-analyses. The extracted ORs and 95% CIs were converted to log
ORs and standard errors (SE) using the RevMan calculator. The Chi-square test and I2 test
were used to evaluate the statistical heterogeneity among the included studies. In the
presence of statistical heterogeneity (p < 0.05 or I2 > 50%) [69], a random effect model was
used, otherwise, a fixed-effect model was adopted [70]. For constitution types with suffi-
cient data and adequate quality, pooled effect sizes (OR and 95% CI) were reported.
Publication bias was assessed using funnel plots if the minimum number of studies was
reached (n ≥ 10) [71]. The symmetry of the plots was examined to evaluate potential
publication bias.
3. Results
3.1. Study Selection
A total of 1629 records were retrieved based on the search strategy. After removing
duplicated records and reviewing titles and abstracts, 84 potentially relevant articles
Behav. Sci. 2022, 12, 423 7 of 22
were identified for further full-text screening. Sixty-six studies were excluded because
the authors failed to provide relevant data, or the studies measured different outcomes,
and did not meet the inclusion criteria, respectively. Overall, eighteen studies were eli-
gible for inclusion in this systematic review and thirteen studies were eligible for me-
ta-analysis. The study selection process and the rationale for study exclusion is reported
in Figure 1.
Figure 1. PRISMA flowchart.
3.2. Characteristics of Included Studies
Details of the included studies are summarized in Table 2. Eleven out of eighteen
studies were conducted among diseased populations, which included hospital outpa-
tients and inpatients. Whereas another seven were focused on healthy populations,
which included samples from biobank, community or institutional groups. The included
studies were published in the past decade, between 2010 and 2021. Five were case-control
studies and thirteen were cross-sectional studies. The total sample size was 14,799, with
an average sample size of 822. The age of the subjects ranged between eighteen and
seventy-five years old. Two studies were focused on female subjects only and the rest
were focused on both males and females. All of the studies were conducted in China (n =
Behav. Sci. 2022, 12, 423 8 of 22
18). Sixteen studies were written in Chinese and the other two were written in English.
The method for depression and TCMBC measurement was based on validated
self-reported questionnaires. Four instruments were used to identify depression: Ham-
ilton Depression Rating Scale (HAMD) (Cronbach’s alpha = 0.8 [72]) contributing the
most studies (n = 6), followed by the Self-Rating Depression Scale (SDS) (Cronbach’s al-
pha = 0.73) [73] (n = 5), Beck Depression Inventory II (BDI-II) (Cronbach’s alpha 0.946
[74]) (n = 5) and Chinese Classification of Mental Disorders (CCMD-3) (n = 1). For studies
using identical depression scales, there were variations for the cut-off points used among
the studies. For example, the cut-off points for SDS ranged between 50 and 52. Two in-
struments used to identify TCMBC included the Chinese Medicine Constitution Ques-
tionnaire (CMCQ) (n = 17) (Cronbach’s alphas in each subscale = 0.72~0.80 [75,76]) and
the Body Constitution Questionnaire (BCQ) (n = 1) (Cronbach’s alpha = 0.8 [55]). Both
instruments consist of different subscales to categorize each type of constitution. Partic-
ipants were categorized according to their highest score among the subscales. Most of the
studies (n = 16) focused on all nine types of TCMBC while the rest (n = 2) focused on
specific constitution types.
Behav. Sci. 2022, 12, 423 9 of 22
Table 2. Characteristics of included studies.
Author, Year
Study
Design
Study Subjects
Sample
Size
Age Range
Sex
Study Area
Depression
Measurement
Body Constitution
Measurement
Constitution
(Specific/All
Nine)
Main Findings
Effect Sizes
OR [95% CI]
Diseased populations
Deng et al., 2019 [77]
CS
Neurological patients
132
42.51 ± 6.03
U
China
SDS
CMCQ
All
YADC and QSC were independently
correlated with depression state.
YADC: 3.021 [0.264–5.619];
QSC: 2.053 [1.256–3.251]
Ke et al., 2019 [78]
CC
Cervical cancer
patients
289
56.84 ± 14.47
F
China
SDS
CMCQ
All
BSC, QSC and QDC were risk factors of
depression in patients with cervical
cancer.
BSC: 2.923 [1.986–3.864];
QSC: 4.158 [1.014–9.869];
QDC: 1.875 [1.067–2.024]
Liao et al., 2017 [79]
CS
Chronic hemodialysis
patients.
467
63 ± 12
U
China
BDI-II
CCMQ
All
QDC is associated with depression in
chronic HD patients
QDC: 4.05 [1.69–9.72]
Liu & Li, 2010 [80]
CC
Post-stroke depressed
patients
90
40–67
U
China
HAMD
CMCQ
QSC, BSC, BC
PSD patients with QSC have a higher
depression tendency compared to BSC
and BC.
QSC: 34.544 [10.325–
117.219];
BCS: 0.192 [0.056–0.682];
BC: 0.234 [0.086–0.632]
Liu et al., 2019 [81]
CC
Patients with
post-cerebral
infarction
252
18–75
U
China
HAMD
CMCQ
All
For post-cerebral infarction, QSC and
QDC are the major body constitutions
which can lead to depression.
QSC: 3.865 [2.124–4.385];
QDC: 2.127 [1.985–3.654]
Pang et al., 2018 [82]
CC
Post-first ischemic
stroke patient
207
61.94 ± 13.54
U
China
HAMD
CMCQ
All
Post-first ischemic stroke depression is
closely related to constitution types of
QSC, PDC and YIDC.
QSC: 4.58 [1.500–14.001];
PDC: 2.98 [1.010–8.605];
YIDC: 0.317 [0.122–0.826]
Sun et al., 2012 [83]
CC
Post stroke patients
353
61.4 ± 9.00
U
China
CCMD-3
CMCQ
All
QSC, YADC and QDC were risk factors
for depression among post stroke
patients
QSC: 2.794 [1.137–7.171];
YADC: 3.757 [1.137–12.118];
QDC: 3.840 [1.357–12.808]
Tang et al., 2020 [84]
CS
Irritable bowel
syndrome patient
147
≥18
U
China
HAMD
CMCQ
All
There is a certain correlation between
TCMBC and depression in IBS patients,
in which QDC and QSC are more likely
to produce depression.
QDC: 4.195 [1.385–12.708];
QSC: 9.607 [2.09–44.157]
Wu et al., 2019 [85]
CS
Diabetic patients
214
52.31 ± 12.25
U
China
HAMD
CMCQ
All
There exists a correlation between
depression after T2DM and Chinese
medicine constitution to some extent.
YIDC: 1.793 [1.027–2.125];
QSC: 1.534 [0.124–0.863];
QDC: 1.219 [0.847–2.121]
Zhao et al., 2020 [62]
CS
Patients with
coronary heart
disease
160
58.41 ± 6.81
U
China
SDS
CMCQ
All
QDC and QSC were independent risk
factors for depression in patients with
CHD.
QDC: 2.491 [1.324–4.731];
QSC: 3.543 [1.175–10.638]
Zhang et al., 2015 [86]
CS
Adult patients with
epilepsy
209
18–70
U
China
HAMD
CMCQ
All
QDC and QSC are prone to depression
in adult patients with epilepsy, while
BC is the protective factor.
QDC: 5.549 [2.194–14.039];
QSC: 4.068 [1.678–9.861];
BC: 0.439 [0.250–0.771]
Healthy populations
Behav. Sci. 2022, 12, 423 10 of 22
Chen et al., 2021 [35]
CS
Women from Taiwan
Biobank
1423
30–70
F
China
NS
BCQ
YADC, YIDC,
PDC
Women who have YADC or YIDC were
more prone to depression.
YADC: 1.047 [1.007–1.089];
YIDC: 1.049 [1.009–1.090]
Deng & Chen, 2011
[58]
CS
General population
7506
≥18
U
China
SDS
CMCQ
ALL
People with QDC, DHC and QSC had
high tendency of depression, while
people with BC had a lower tendency
of depression.
BC: 0.601 [0.525–0.689];
QDC: 1.556 [1.305–1.855];
DHC: 2.140 [1.705–2.686];
QSC: 2.154 [1.720–2.697]
Jiang et al., 2018 [59]
CS
Beijing Railway
crews
281
20–35
U
China
SDS
CMCQ
ALL
QDC was significantly correlated to
depression among railway crews.
QDC: 2.03 [1.05–3.94]
Qiu & Xu, 2015 [60]
CS
University students
764
NS
U
China
BDI
CMCQ
ALL
BC is the protective factor for
depression among the students, while
QDC and QSC are the risk factors.
BC: 0.976 [0.978–1.001];
QDC: 1.019 [0.987–1.015];
QSC: 1.042 [0.989–1.016]
Qiu & Xu, 2016 [87]
CS
University students
684
NS
U
China
BDI
CMCQ
ALL
QDC, YADC, YIDC, QSC, BC, and BSC
were the predictors for depression.
BC: 1.013 [−0.026, −0.001];
QDC: 1.649 [0.039–0.061];
YADC: 1.234 [−0.031, −0.011];
YIDC: 1.185 [0.005–0.029];
QSC: 1.878 [0.051–0.075];
BSC: 1.174 [−0.030, −0.003]
Xiong et al., 2019 [38]
CS
University students
950
NS
U
China
BDI-II
CMCQ
ALL
BC is the protective factor while QDC
and QSC are the risk factors for
depression among university students.
BC: 0.380 [0.236–0.610];
QDC: 1.693 [1.111–2.578];
QSC: 2.994 [1.965–4.561]
Zhang et al., 2019 [61]
CS
University students
671
20.40 ± 1.48
U
China
BDI-II
CMCQ
ALL
Results showed that YADC, YIDC,
QDC, PDC, ISC and QSC were risk
factors of depression.
YADC: 3.486 [1.902–6.389];
YIDC: 2.085 [1.018–4.267];
QDC: 6.015 [ 3.142–11.514];
PDC: 2.556 [1.145–5.707];
ISC: 8.888 [4.406–17.929];
QSC: 16.049 [7.919–32.525]
Note: TCMBC, Traditional Chinese medicine body constitution; CS, cross-sectional study; CC, case-control study; NS, not specify or report in the article; U, uni-
sex; F, female; SDS, Self-Rating Depression Scale; BDI-II, Beck Depression Inventory II; HAMD, Hamilton Depression Rating Scale; CCMD-3, Chinese Classifica-
tion of Mental Disorders; CMCQ, Chinese Medicine Constitution Questionnaire; BCQ, Body Constitution Questionnaire; QSC, Qi-stagnation constitution; BSC,
Blood-stasis constitution; BC, Balanced constitution; YADC, Yang-deficiency constitution; YIDC, Yin-deficiency constitution; PDC, Phlegm-damp constitution;
HD, hemodialysis; PSD, Post-stroke depression; IBS, Irritable bowel syndrome; T2DM, Type 2 diabetes mellitus; CHD, coronary heart disease.
Behav. Sci. 2022, 12, 423 11 of 22
3.3. Quality Appraisal
The quality assessment of the included studies is reported in Table 3. Seven studies
were rated as good quality, seven were medium quality and four were poor quality. The
NOS scores of all included studies ranged between 5 and 8. The average score for case
control studies was 5.2 and for cross-sectional studies was 6.5. Poor quality studies were
excluded from the meta-analyses. The inter-rater reliability for this review was 94%.
Table 3. Quality assessment of the included studies by the Newcastle–Ottawa Scale (NOS).
Author, Year
Selection
Comparability
Outcome
Total Score
Chen et al., 2021 [35]
★★
★★
★★★
7
Deng & Chen, 2011
[58]
★
★
★★★
5
Deng et al., 2019 [77]
★
★★
★★★
5
Jiang et al., 2018 [59]
★★
★
★★★
6
Ke et al., 2019 [78] cc
★★★
★
★
5
Liao et al., 2017 [79]
★★★
★★
★★★
8
Liu & Li, 2010 [80] cc
★★★
★
★
5
Liu et al., 2019 [81] cc
★★★
★
★★
6
Pang et al., 2018 [82] cc
★★★
★
★
5
Qiu & Xu, 2015 [60]
★★
★
★★★
6
Qiu & Xu, 2016 [87]
★
★
★★★
6
Sun et al., 2012 [83] cc
★★★
★
★
5
Tang et al., 2020 [84]
★★
★
★★★
6
Wu et al., 2019 [85]
★★
★
★★★
7
Xiong et al., 2019 [38]
★★
★
★★★
7
Zhang et al., 2015 [86]
★★
★
★★★
6
Zhang et al., 2019 [61]
★★
★
★★★
7
Zhao et al., 2020 [62]
★★★
★
★★★
7
Note: cc, case control study. A maximum of one star can be awarded for each numbered item within
the selection and exposure section. A maximum of two stars can be given for the comparability
section. The maximum scores for case-control studies and cross-sectional studies are 9 and 10, re-
spectively. For the quality of case-control studies, it was considered as poor if the score was 0 to 5
and good if the score was 6 to 9. For the quality of cross-sectional studies, it was considered as poor
if the score was 0 to 4, medium if the score was 5 to 6, good if the score was 7 to 8, and very good if
the score was 9 to 10.
3.4. Systematic Review of Associations between TCMBC and Depression
All nine types of TCMBC were showed to be associated with depression, with QSC
contributing the most (n = 15), followed by QDC (n = 14), BC (n = 6), YADC (n = 5), YIDC
(n = 5), BSC (n = 3), PDC (n = 2), DHC (n = 1), and ISC (n = 1).
3.4.1. Qi-Stagnation Constitution
Among the studies that revealed a link between QSC and depression, diseased
populations were more frequently observed, with a higher prevalence among post-stroke
patients [80–82,84], followed by cervical cancer patients [78], diabetic patients [86], epi-
leptic patients [87], heart disease patients [62], irritable bowel syndrome (IBS) patients
[85] and neurological patients [77]. In addition, the other five studies were carried out
among general populations, which included university students [38,60,61,83], and young
adults [58]. These studies showed consistent results where QSC significantly predicted
depression. Four studies were excluded from the meta-analysis due to poor quality
[78,80,82,84] and the other one was excluded due to differences in the study design [81].
Behav. Sci. 2022, 12, 423 12 of 22
3.4.2. Qi-Deficiency Constitution
Among the studies that found a correlation between QDC and depression, eight
were conducted on diseased populations, including cervical cancer patients [78], chronic
hemodialysis patients [79], diabetic patients [86], epileptic patients [87], heart disease
patients [62], IBS patients [85] and post-stroke patients [81,84], Whereas in general pop-
ulations, most studies focused on university students [38,60,61,83], followed by railway
crews [59] and young adults [58]. All studies suggest that QDC is a significant risk factor
for depression. Three studies were excluded from the meta-analysis due to poor quality
[78,84] and differences in the study design [81].
3.4.3. Yang-Deficiency Constitution
Of the five studies indicating a link between YADC and depression, two were from
diseased populations, which included neurological patients [77] and post-stroke patients
[84]. The rest were from university students [61,83] and women [35]. The consistent
findings suggest that YADC is a risk factor for depression. One study was excluded from
the meta-analysis due to poor quality [84].
3.4.4. Yin-Deficiency Constitution
Five studies showing that YIDC is significantly related to depression were con-
ducted among diabetic patients [86], post-stroke patients [82], women [35] and university
students [61,83]. There were inconsistent findings among the studies, in which Pang et al.
showed that YIDC was negatively associated with depression. While the rest showed that
YIDC was positively associated with depression [35,61,83,86]. One study was excluded
from the meta-analysis due to poor quality [82].
3.4.5. Blood-Stasis Constitution
Three out of eighteen included studies indicated that BSC was correlated with de-
pression among cervical cancer patients [78], post-stroke patients [80], and university
students [83]. Inconsistent findings were observed among the included studies. Two
studies found that BSC was negatively correlated to depression [80,83]. In contrast, Ke et
al. [78] found that BSC was positively correlated with depression. No meta-analysis was
performed for this constitution type because there was only a single study of sufficient
quality [83].
3.4.6. Phlegm-Dampness Constitution
Only two studies demonstrated a link between PDC and depression. One was con-
ducted among post-stroke patients [82] and the other among university students [61].
Both studies showed consistent results, suggesting that PDC was a risk factor for de-
pression. No meta-analysis was performed for this constitution type because there was
only a single study of sufficient quality [61].
3.4.7. Damp-Heat Constitution
There was one study conducted among young adults which revealed that DHC was
correlated with depression [58]. The findings showed that DHC was a risk factor for de-
pression. No meta-analysis was performed for this constitution type due to the insuffi-
cient number of studies.
3.4.8. Inherited Special Constitution
Only one study focused on university students found that ISC was related to de-
pression [61]. Their findings suggested that ISC was a risk factor for depression. No me-
ta-analysis was performed for this constitution type due to the insufficient number of
studies.
Behav. Sci. 2022, 12, 423 13 of 22
3.4.9. Balanced Constitution
Six out of eighteen included studies demonstrated a relationship between balanced
constitution and depression. The majority of the studies were focused on general popu-
lations, such as university students [38,60,83] and young adults [58]. The rest were fo-
cused on epileptic patients [87] and post-stroke patients [80]. All studies showed con-
sistent results, in which BC was found to be a protective factor for depression. One study
was excluded from meta-analysis because of differences in the study design [80].
3.5. Meta-Analyses of Association between TCM Body Constitution and Depression
For the association between each type of TCMBC and depression, a meta-analysis
was conducted only when there was sufficient data (n ≥ 2 and with adequate quality).
3.5.1. Qi-Stagnation Constitution
Among eighteen included studies, ten studies involving 11,437 subjects reported an
association between QSC and depression. The random effects model was used because
the statistical heterogeneity of the included studies was significant (I2 = 94%). The results
showed that the association between QSC and depression was significant, with a pooled
OR and 95% CI of 3.12 [1.80–5.40] (see Figure 2).
Figure 2. Forest plot of studies on association between QSC and depression. Note: red square rep-
resents the result of each study; line represents the 95% CI of the results; diamond represents the
pooled results.
3.5.2. Qi-Deficiency Constitution
Eleven studies with a total of 12,053 subjects reported an association between QDC
and depression. The random effects model was used because the statistical heterogeneity
of the included studies was significant (I2 = 89%). The results showed that the association
between QDC and depression was significant, with a pooled OR and 95% CI of 2.15
[1.54–3.01] (see Figure 3).
Figure 3. Forest plot of studies on association between QDC and depression. Note: red square
represents the result of each study; line represents the 95% CI of the results; diamond represents
the pooled results.
Behav. Sci. 2022, 12, 423 14 of 22
3.5.3. Yang-Deficiency Constitution
Four studies with a total of 2910 subjects reported an association between YADC
and depression. The random effects model was used because the statistical heterogeneity
of the included studies was significant (I2 = 81%). The results showed that the association
between YADC and depression was significant, with a pooled OR and 95% CI of 1.89
[0.71–5.03] (see Figure 4).
Figure 4. Forest plot of studies on association between YADC and depression. Note: red square
represents the result of each study; line represents the 95% CI of the results; diamond represents
the pooled results.
3.5.4. Yin-Deficiency Constitution
Four studies with a total of 2992 subjects reported an association between YIDC and
depression. The random effects model was used because the statistical heterogeneity of
the included studies was significant (I2 = 57%). The results showed that the association
between YIDC and depression was significant, with a pooled OR and 95% CI of 1.41
[0.91–2.20] (see Figure 5).
Figure 5. Forest plot of studies on association between YIDC and depression. Note: red square
represents the result of each study; line represents the 95% CI of the results; diamond represents
the pooled results.
3.5.5. Balanced Constitution
Five studies with a total of 10,113 subjects reported an association between BC and
depression. The random effects model was used because the statistical heterogeneity of
the included studies was significant (I2 = 94%). The results showed that the association
between BC and depression was significant, with a pooled OR and 95% CI of 0.60 [0.40–
0.90] (see Figure 6).
Figure 6. Forest plot of studies on association between BC and depression. Note: red square rep-
resents the result of each study; line represents the 95% CI of the results; diamond represents the
pooled results.
Behav. Sci. 2022, 12, 423 15 of 22
3.6. Risk of Bias
A visualization of the funnel plots suggests no clear evidence of publication bias (see
Figures 7 and 8). For other constitution types, we were unable to perform a publication
bias analysis due to the small number of studies [71].
Figure 7. Funnel plot of studies on association between QSC and depression. Note: dot represents
individual studies; blue dotted line represents the overall effect.
Figure 8. Funnel plot of studies on association between QDC and depression. Note: dot represents
individual studies; blue dotted line represents the overall effect.
3.7. Certainty of Evidence
The detailed GRADE ratings for each meta-analysis are reported in Table 4. As all
the included studies in these meta-analyses were observational studies, the level of cer-
tainty was initially rated as low. One point was deducted for all meta-analyses due to
inconsistency (due to the presence of statistical heterogeneity). However, for the associa-
tions of QSC and QDC with depression, the quality of evidence was increased by one
point due to the large magnitude of effect. The overall quality of evidence of was rated as
very low.
Table 4. GRADE assessment of all meta-analyses.
Number
of Studies
Study
Design
Risk of
Bias
Inconsistency
Imprecision
Indirectness
Publication
Bias
Other
Considerations
Number of
Subjects
Effect Sizes
[95% CI]
Overall Quality
of Evidence
QSC
10
Observation
al studies
Not
serious
Serious a
Not serious
Not serious
Not detected
Very strong
association c
11,437
3.12 [1.80,
5.40]
Low
QDC
11
Observation
al studies
Not
serious
Serious a
Not serious
Not serious
Not detected
Very strong
association c
12,053
2.15 [1.54,
3.01]
Low
YADC
4
Observation
al studies
Not
serious
Serious a
Not serious
Not serious
Not detected
b
None
2910
1.89 [0.71,
5.03]
Very low
YIDC
4
Observation
al studies
Not
serious
Serious a
Not serious
Not serious
Not detected
b
None
2992
1.41 [0.91,
2.20]
Very low
BC
5
Observation
Not
Serious a
Not serious
Not serious
Not detected
None
10,113
0.60 [0.40,
Very low
Behav. Sci. 2022, 12, 423 16 of 22
al studies
serious
b
0.90]
Note: a significant heterogeneity was detected (I2 > 50%); b unable to perform publication bias as-
sessment due to small number of studies; c magnitude of the effect was large (OR > 2); Low quality
indicated that the authors’ confidence in the effect estimate is limited; Very low quality indicated
that the authors have very little confidence in the estimated effect.
4. Discussion
Traditional Chinese medicine body constitutions (TCMBC) are classified based on
the harmony and balance of Yin-Yang, Qi and blood within the human body. There are
nine types of TCMBC, where Balanced constitution (BC) is a neutral constitution, and the
rest are the biased constitutions, namely Qi-stagnation (QSC), Blood-stasis (BSC),
Qi-deficiency constitution (QDC), Yin-deficiency constitution (YIDC), Yang-deficiency
constitution (YADC), Phlegm-dampness (PDC), Damp-heat constitution (DHC) and In-
herited special constitution (ISC) [34]. This review shows that all nine types of TCMBC
were associated with depression. Of the nine constitutions, QSC, QDC, BC, YADC, YIDC,
BSC and PDC showed significant relationships with depression among both diseased
and general populations. QSC, QDC, YADC and YIDC were independent risk factors for
depression. When compared to other biased constitutions, people with QSC and QDC
were 3.12 and 2.15 times more likely to be depressed, respectively. The strong positive
associations between biased TCMBC (e.g., QSC, QDC, YADC and YIDC) and depression
could be explained by the interactions between fundamental substances (essence, Qi,
blood, body fluids and spirit) and viscera (liver, spleen, lung, heart and kidney). Gener-
ally, the blockage of Qi and blood and the abnormal liver functions are considered cor-
related to depression in TCM.
According to TCM, Qi plays an essential role in propelling, warming and trans-
forming [31,32]. There are variations in the functions of Qi in different viscera. The pro-
pelling effect of Qi is responsible for stimulating and maintaining the normal function of
internal organs [88]. For example, heart-Qi is responsible for promoting blood circulation
[89], whereas liver-Qi regulates the smooth movement of Qi [43,90]. The impaired pro-
pelling function of Qi can cause hypofunction of the viscera and subsequent deficiency
problems [91]. Furthermore, Qi with a warming effect is called Yang-Qi. In TCM,
Yang-Qi in the heart warms and dredges our blood vessels to promote blood circulation
[92], while Yang-Qi in the spleen warms and transforms food and water [93,94], ensuring
good digestion and absorption [94]. If the warming effect of Qi is weakened, it will result
in restricted circulation of Qi and blood, as well as the devitalization of the visceral func-
tions. Additionally, Qi-transformation is vital in maintaining the balance of fundamental
substances within our body [32]. For example, Qi is involved in producing and trans-
forming other fundamental substances, such as blood, essence and body fluid. If the
transforming function of Qi is weakened, physiological functions will be affected, re-
sulting in various diseases. Overall, a lack or deficiency of Qi will lead to the develop-
ment of weak immunity. In TCM, the liver plays important roles in regulating emotions
and the maintenance of the movement of Qi and blood [31,43,45]. When the liver func-
tions normally, free flow of Qi and blood is maintained, ensuring the transport of essen-
tial nutrients to other viscera, which results in good physical and mental health [45]. If the
liver’s function of dispersion and dredging is abnormal, the flow of Qi and blood in the
body may be obstructed, which can result in various problems, such as insomnia, mel-
ancholy, sentimentality, mood swings and even depression [31,43,48,51]. Disruptions of
Qi and blood in viscera will affect a person’s mental activities, and abnormal mental ac-
tivities can affect the Qi and blood in viscera, as well. For example, excessive emotions
like panic, stress and sadness can cause dysfunctions of Qi, blood and viscera, and
eventually lead to the development of depression [43].
On the contrary, BC is shown to be a significant protective factor against depression.
This result was expected, because BC is defined as a neutral and harmonious constitution
type, with a balance of Yin-Yang, Qi and blood in the body. People with this constitution
Behav. Sci. 2022, 12, 423 17 of 22
usually have an optimistic personality and good adaptability. High optimism helps re-
duce the incidence of depression because optimistic people often think positively and are
more resistant to stress. Moreover, change induces negative emotions, such as stress,
anxiety and even depression. People with good adaptability can handle and adapt to
changes quickly; their ability to cope with changed or changing situations can subse-
quently minimize their risk of depression. Besides, people with BC tend to practice
healthier lifestyles compared to people with biased TCMBCs. Heathy lifestyles charac-
terized by balanced diet and sufficient exercise are shown to be beneficial for mental
health [95].
The strength of this review is that its findings can contribute to the prevention and
treatment of depression through the modification of TCMBC. Since this review identified
those with QSC and QDC as populations at high risk for depression, we suggest that
screening of TCMBC be added to depression screening protocols. When a person is
identified as either QSC or QDC, they should be considered at high risk for depression.
Since TCMBC is modifiable, depression can actually be prevented before it even develops
in people with QSC and QDC. In order to modify these biased constitutions towards a
balanced constitution, moderate amount of exercise, such as yoga and cardio, is highly
recommended for people with QSC and QDC, as it can help promote the circulation of Qi
and blood in the body [31]. Moreover, sleeping at regular times and getting adequate
sleep is vital for nourishing the Qi [31]. As for diet, these people should eat a greater va-
riety of foods that can nourish the blood and help with Qi movement, such as dark leafy
greens, bean sprouts, berries and red meats [31].
This review has several limitations. First, the application of TCMBC is still in infancy
in countries other than China, and the sources of the included studies were all from
China. The majority of the included studies were written in Chinese, even though we
searched four English databases and six other Chinese databases. This could be due to
the lack of application of TCMBC in countries other than China. Currently, there is only
one previous study related to TCMBC and depression among non-Chinese populations,
conducted among African students studying in China [96]. However, the study is not
included in our review due to different outcome measures. Thus, the findings of this re-
view cannot be generalized to other populations. Secondly, the study design of the in-
cluded studies were mostly cross-sectional studies, followed by case-control studies. No
case-control studies were included in the meta-analysis. Hence, the temporal relationship
and the causal link between TCMBC and depression is unknown. Third, all the included
studies were observational studies using self-reported questionnaires as the measure-
ment tool; therefore, recall bias may be present. Fourth, there was presence of high het-
erogeneity. This could be due to the variations in sample sizes, sample populations and
measurement tools. Fifth, the validation of TCMBC-related questionnaires are limited to
the Chinese and English languages only. This could explain why TCMBC is not widely
applicable in other countries. Further research is likely to significantly impact our confi-
dence regarding the estimated effects, as the levels of certainty of the current review
measured by GRADE were rated as low and very low, respectively.
5. Conclusions
This review demonstrated that Qi-stagnation, Qi-deficiency, Yang-deficiency,
Yin-deficiency and Balanced constitutions are significant predictors for depression, of
which, Balanced constitution is the protective factor. Because most of the included stud-
ies were cross-sectional, we suggest that more case-control and cohort studies be ana-
lyzed to confirm the association between TCMBC and depression.
Author Contributions: Conceptualization: C.N.F., Y.M.L. and F.L.N.; Data curation: S.Y.Y., M.S.
and F.L.N.; Formal analysis: S.Y.Y., M.S. and F.L.N.; Funding acquisition: C.N.F., Y.M.L. and
F.L.N.; Investigation: S.Y.Y., M.S., F.L.N., C.N.F. and Y.M.L.; Methodology: C.N.F., Y.M.L., F.L.N.,
M.S. and S.Y.Y.; Project administration: C.N.F., Y.M.L., F.L.N., M.S. and S.Y.Y.; Supervision: C.N.F.,
Behav. Sci. 2022, 12, 423 18 of 22
Y.M.L. and F.L.N.; Validation: C.N.F., Y.M.L., F.L.N., M.S. and S.Y.Y.; Writing—original draft:
S.Y.Y. and C.N.F.; Writing—review & editing: C.N.F., Y.M.L., F.L.N., M.S. and S.Y.Y. All authors
have read and agreed to the published version of the manuscript.
Funding: This study was supported by the Universiti Tunku Abdul Rahman Research Fund
(UTARRF), (Project number IPSR/RMC/UTARRF/2019-C2/F01 and
IPSR/RMC/UTARRF/2022-C1/F02).
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the
design of the study; in the collection, analyses, or interpretation of data; in the writing of the man-
uscript; or in the decision to publish the results.
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