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Development of a Brief Diabetes Distress Screening Instrument
Open accessAbstract
PURPOSE: Previous research has documented that diabetes distress, defined as patient concerns about disease management, support, emotional burden, and access to care, is an important condition distinct from depression. We wanted to develop a brief diabetes distress screen instrument for use in clinical settings. METHODS: We assessed 496 community-based patients with type 2 diabetes on the previously validated, 17-item Diabetes Distress Scale (DDS17) and 6 biobehavioral measures: glycated hemoglobin (HbA(1c)); non-high-density-lipoprotein (non-HDL) cholesterol; kilocalories, percentage of calories from fat, and number of fruit and vegetable servings consumed per day; and physical activity as measured by the International Physical Activity Questionnaire. RESULTS: An average item score of > or =3 (moderate distress) discriminated high- from low-distressed subgroups. The 4 DDS17 items with the highest correlations with the DDS17 total (r = .56-.61) were selected. Composites, comprised of 2, 3, and 4 of these items (DDS2, DDS3, DDS4), yielded higher correlations (r=.69-.71). The sensitivity and specificity of the composites were .95 and .85, .93 and .87, and .97 and .86, respectively. The DDS3 had a lower sensitivity and higher percentages of false-negative and false-positive results. All 3 composites significantly discriminated subgroups on HbA(1c), non-HDL cholesterol, and kilocalories consumed per day; none discriminated subgroups on fruit and vegetable servings consumed per day; and only the DDS3 yielded significant results on the International Physical Activity Questionnaire. Because of its psychometric properties and brevity, the DDS2 was selected as a screening instrument. CONCLUSIONS: The DDS2 is a 2-item diabetes distress screening instrument asking respondents to rate on a 6-point scale the degree to which the following items caused distress: (1) feeling overwhelmed by the demands of living with diabetes, and (2) feeling that I am often failing with my diabetes regimen. The DDS17 can be administered to those who have positive findings on the DDS2 to define the content of distress and to direct intervention.
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“Previous analyses identified that the DDS2 had good sensitivity and specificity with the DDS17 (7) and was considered a reliable screening composite for use in clinical practice.”
From When Is Diabetes Distress Clinically Meaningful? (2012) · cites this paper as [7]
In the citing paper
“Previous analyses identified that the DDS2 had good sensitivity and specificity with the DDS17 (7) and was considered a reliable screening composite for use in clinical practice.”
From When Is Diabetes Distress Clinically Meaningful? (2012) · cites this paper as [7]
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“Short forms and screeners such as the DDS2 and PAID-5 are also available (3, 29-31).”
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“Diabetes distress is defined as patient concerns about disease management, support, emotional burden, and access to care, and measured by the Diabetes Distress Scale developed by Fisher and colleagues [47] in 2008.”
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“Diabetes distress Distress was assessed with the Diabetes Distress Scale (DDS); a 17-item measure with questions about disease management, support, emotional burden and access to care [25].”
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“5 on the two-item Diabetes Distress Screener (15) (confirmed later by the full scale).”
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“The DDS-17 displays excellent internal consistency indicating that the component questions are measuring a similar construct, [11] and like PAID there is also a brief version; the DDS-2, [20].”
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Diabetes-Related Distress Assessment among Type 2 Diabetes Patients
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“The brief form of DDS is designed for use in clinical settings not just for research purposes [8].”
BackgroundDiabetes distress in Type 1 diabetes—a new measurement fit for purpose
Joensen, L. E., Tapager, I., & Willaing, I. (2013) · Diabetic Medicine · doi:10.1111/dme.12241 · Cited by 93
Simmons, D. S., Prevost, A. T., Bunn, C., Holman, D., Parker, R. A., Cohn, S. R., Donald, S., Paddison, C. A. M., Ward, C., Robins, P., et al. (2015) · PLoS ONE · doi:10.1371/journal.pone.0120277 · Cited by 95
“The questionnaire included socio-demographic and clinical questions (eg medications), and measures of depression (PHQ8), quality of life (EQ5D), diabetes self-efficacy, the Revised Diabetes Knowledge Scale (RDKS), diabetes distress, and medication adherence [12–17].”
Crabtree, T. S. J., Griffin, T. P., Yap, Y. W., Narendran, P., Gallen, G., Furlong, N. J., CRANSTON, I. C., Chakera, A. J., Philbey, C., Karamat, M. A., et al. (2023) · Diabetes Care · doi:10.2337/dc23-0635 · Cited by 95
“Secondary outcomes included CGM metrics time in range (TIR) (70–180mg/dL), time below range (TBR) (<70 mg/dL), glucose management indicator (GMI) (estimated HbA1c), Diabetes Distress Scale 2 (DDS2) score (18), Gold score (19), event rates, weight, BMI, and user opinion of HCL (using a 7-point Likert scale where 1 = st…”
Gagliardino, J. J., Arrechea, V., Assad, D., Gagliardino, G. G., González, L., Lucero, S., Rizzuti, L., Zufriategui, Z., & Clark, C. M. (2012) · Diabetes/Metabolism Research and Reviews · doi:10.1002/dmrr.2368 · Cited by 90
“Data for outcomes were collected identically for each group using different instruments: (a) the QUALIDIAB data set at the beginning and at 12 months, (b) an abbreviated QUALIDIAB data collection at 6 months, (c) a Diabetes Distress Screening questionnaire [30] before and after the education courses and (d) a peer sat…”
MethodAsuzu, C. C., Walker, R. J., Williams, J. S., & Egede, L. E. (2016) · Journal of Diabetes and its Complications · doi:10.1016/j.jdiacomp.2016.09.013 · Cited by 90
“(26) DDS17 has good internal reliability (Cronbach’s alpha 0.”
A review of the mental health issues of diabetes conference
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“According to the diabetes distress screening instrument (23), diabetes distress is defined as distress linked specifically to diabetes and its management (24).”
BackgroundFood insecurity and diabetes self-management among food pantry clients
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“, asking questions) as measured by an adapted version of the Perceived Efficacy in PatientPhysician Interactions scale (PEPPI) [43], depressive symptoms (PHQ8) [44], the 4-item (short) version of the diabetes distress scale [45,46], physical activity [47-49], visits to the emergency room and hospital, health literacy…”
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“Previous cross-sectional research, primarily among people with type-2 diabetes, has found high diabetes distress to be associated with low quality of life and difficulties in managing diabetes in everyday life such as low self-efficacy, low diabetes empowerment, unhealthy diet and less physical activity [4,9,11–14].”
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“The scale was translated into many languages (3,2632) and has been used frequently in different age groups (33-40), in different patient groups (41-44), and in different ethnic groups (45-49).”
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“of patient screening for inclusion (19).”
Kumar, S., Moseson, H., Uppal, J., & Juusola, J. L. (2018) · The Diabetes Educator · doi:10.1177/0145721718765650 · Cited by 68
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“[36] The sensitivity and specificity ranged from 0.”
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“2% accordingly.(10) The DDS2 evaluates the severity of feeling overwhelmed with the demands of living with diabetes and feelings of failure with the diabetes routine.”
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“We examined general negative affect as well as affect specifically related to diabetes as predictors of intentional insulin restriction (21,22).”
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“[6] If a patient answers affirmatively to the DDS2 questions, the DDS17 can be administered to help define the content of the distress and to direct intervention.”
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“The DDS consisted of 17 items that use the Likert scale, with each item scored 1¼ not a problem, 2¼ a slight problem, 3¼ a moderate problem, 4 ¼ somewhat serious problem, 5 ¼ a serious problem, and 6 ¼ a very serious problem concerning distress experienced over the past month.”
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Religion, spirituality, coping, and resilience among African Americans with diabetes
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Diabetes distress in males and females with type 1 diabetes in adolescence and emerging adulthood
Lašaitė, L., Dobrovolskienė, R., Danytė, E., Stankutė, I., Ražanskaitė-Virbickienė, D., Schwitzgebel, V., Marčiulionytė, D., & Verkauskienė, R. (2016) · Journal of Diabetes and its Complications · doi:10.1016/j.jdiacomp.2016.08.013 · Cited by 62
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“Diabetes distress was measured using 4 questions from the Diabetes Distress Scale (scale from 0 to 5) [10]; a higher score communicates that an individual has more diabetes-related stress.”
Arifin, B., Perwitasari, D. A., Thobari, J. A., Cao, Q., Krabbe, P. F. M., & Postma, M. J. (2017) · Value in Health Regional Issues · doi:10.1016/j.vhri.2017.03.010 · Cited by 52
“Although a generic instrument to measure psychological distress can be quite useful for recognizing distressed T2DM outpatients, a more specific DM-related identification of psychological distress may help to choose the appropriate intervention, which will ultimately improve prospects for adequate therapies and better…”
Winchester, R. J., Williams, J. S., Wolfman, T. E., & Egede, L. E. (2015) · Journal of Diabetes and its Complications · doi:10.1016/j.jdiacomp.2015.11.010 · Cited by 52
“93) questionnaire that assesses diabetes-related emotional distress in research and clinical practice [26,27].”
BackgroundCuiping, X., Zhang, Li, D., Liu, Q., Wu, H., Xu, Z.-J., Xue, X.-J., & Gao, Q. (2013) · Neuropsychiatric Disease and Treatment · doi:10.2147/ndt.s49798 · Cited by 50
“3 Diabetes distress is defined as patient concern about disease management, support, emotional burden, and access to care, 4 and has been considered as part of a more global approach to the psychologic issues associated with diabetes.”
Rees, G., O’Hare, F., Saeed, M., Sudholz, B., Sturrock, B. A., Xie, J., Speight, J., & Lamoureux, E. L. (2017) · BMJ Open Diabetes Research & Care · doi:10.1136/bmjdrc-2016-000307 · Cited by 50
Development and Testing of a 3-Item Screening Tool for Problematic Internet Use
Moreno, M. A., Arseniev-Koehler, A., & Selkie, E. (2016) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2016.05.067 · Cited by 45
“This follows previous scale development designs such as those outlined by Fisher et al.(22) We noted that the sensitivity of the PRIUSS-3 was 100% in the first testing set and 90% in the second testing set, which consisted of younger teens who were Dutch.”
Fisher, L., Hessler, D., Masharani, U. B., & Strycker, L. A. (2014) · Diabetic Medicine · doi:10.1111/dme.12403 · Cited by 49
Self-citationMood and metabolism: Anhedonia as a clinical target in Type 2 diabetes
Carter, J., & Swardfager, W. (2016) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2016.04.002 · Cited by 56
“…failing with my diabetes regime”, exhibit the same relationships with these outcome measures, offering a more efficient screening instrument, which can be followed up with additional DDS questions, if distress is detected, in order to direct interventions (Fisher et al., 2012; Fisher et al., 2008).”
Depressive symptoms among elderly diabetic patients in Vietnam
Vu, H. T. T., Nguyen, T. X., Nguyen, H. T. T., Le, T. A., Nguyen, T. N., Nguyen, A. T., Nguyen, T. T. H., Nguyen, L. H., Nguyen, C. T., Tran, B. X., et al. (2018) · Diabetes Metabolic Syndrome and Obesity · doi:10.2147/dmso.s179071 · Cited by 48
Fayed, A. A., Alradini, F. A., Alzuhairi, R., Aljuhani, A. E., Alrashid, H. R., Alwazae, M., & Alghamdi, N. R. (2021) · Primary care diabetes · doi:10.1016/j.pcd.2021.12.004 · Cited by 52
Targeting diabetes distress: The missing piece of the successful type 1 diabetes management puzzle
Pallayova, M., & Taheri, S. (2014) · Diabetes Spectrum · doi:10.2337/diaspect.27.2.143 · Cited by 45
Sharp, L. K., Tilton, J. J., Touchette, D. R., Xia, Y., Mihailescu, D., Berbaum, M. L., & Gerber, B. S. (2018) · Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy · doi:10.1002/phar.2058 · Cited by 45
Wu, S., Ell, K., Gross-Schulman, S. G., Sklaroff, L. M., Katon, W. J., Nezu, A. M., Lee, P.-J., Vidyanti, I., Chou, C.-P., & Guterman, J. J. (2013) · Contemporary Clinical Trials · doi:10.1016/j.cct.2013.11.002 · Cited by 45
“Also included in the assessment are the summary ofDiabetes Self-Care Activities Questionnaire to assess self-reported adherence [56], the Whitty 9-item questionnaire to assess diabetes symptoms [57], and the brief two-item Diabetes Distress Scale to screen for distress [58].”
MethodFranks, M. M., Lucas, T., Stephens, M. A. P., Rook, K. S., & Gonzalez, R. (2010) · Family Relations · doi:10.1111/j.1741-3729.2010.00626.x · Cited by 43
Diabetes distress and its clinical determinants in patients with type II diabetes
Parsa, S., Aghamohammadi, M., & Abazari, M. (2019) · Diabetes & Metabolic Syndrome Clinical Research & Reviews · doi:10.1016/j.dsx.2019.02.007 · Cited by 43
Effect of peer support on diabetes distress: a cluster randomized controlled trial
Ju, C., Shi, R., Li, Y., Ye, X., Jia, M., Han, J., Yang, T., Lu, Q. R., Jin, H., Cai, X., et al. (2018) · Diabetic Medicine · doi:10.1111/dme.13625 · Cited by 41
Diabetes distress and related factors in South African adults with type 2 diabetes
Ramkisson, S., Pillay, B. J., & Sartorius, B. K. D. (2016) · Journal of Endocrinology Metabolism and Diabetes of South Africa · doi:10.1080/16089677.2016.1205822 · Cited by 41
“The aim of this paper was: (1) to identify the level of diabetes-related distress in a cohort of diabetes type 2 patients in KwaZulu-Natal and (2) to identify the factors that contribute to diabetes-related distress.”
BackgroundChew, B., Vos, R. C., Pouwer, F., & Rutten, G. E. H. M. (2018) · Diabetes Research and Clinical Practice · doi:10.1016/j.diabres.2018.05.021 · Cited by 41
“The 20-item Problem Areas in Diabetes (PAID-20) questionnaire and its shorter 5-item version [8] are more strongly associated with depressive symptoms and quality of life [9] than the 17-item Diabetes Distress Scale (DDS-17) and its shorter version DDS-2 [10].”
InfluentialImproving Diabetes Care: Should We Reconceptualize Diabetes Burnout?
Abdoli, S., Jones, D. H., Vora, A. C., & Stuckey, H. L. (2019) · The Science of Diabetes Self-Management and Care · doi:10.1177/0145721719829066 · Cited by 41
“”(14-16) Diabetes distress considers the unique and hidden emotional burden or frustration that comes with living with diabetes and considers ongoing concerns, worries, and fears of diabetes management as well as diabetes complications.(17-21)”
BackgroundHessler, D., Fisher, L., Bowyer, V., Dickinson, L. M., Jortberg, B. T., Kwan, B. M., Fernald, D. H., Simpson, M., & Dickinson, W. P. (2019) · BMC Family Practice · doi:10.1186/s12875-019-1012-x · Cited by 42
Self-citationSexual health and function in women with diabetes
Winkley, K., Kristensen, C. B., & Fosbury, J. (2021) · Diabetic Medicine · doi:10.1111/dme.14644 · Cited by 46
Wang, R., Wu, L., & Hsu, H. (2011) · Journal of Advanced Nursing · doi:10.1111/j.1365-2648.2011.05701.x · Cited by 40
“Most people with diabetes are distressed about their diabetes and its management (Fisher et al. 2008).”
BackgroundMcLeod, M., Stanley, J., Signal, V., Stairmand, J., Thompson, D., Henderson, K., Davies, C., Krebs, J., Dowell, A., Grainger, R., et al. (2020) · Diabetologia · doi:10.1007/s00125-020-05261-x · Cited by 36
Langendoen‐Gort, M., Groeneveld, L., Prinsen, C. A. C., Beulens, J. W. J., Elders, P. J. M., Halperin, I. J., Mukerji, G., Terwee, C. B., & Rutters, F. (2022) · Reviews in Endocrine and Metabolic Disorders · doi:10.1007/s11154-022-09734-9 · Cited by 43
Esbitt, S. A., Tanenbaum, M. L., & Gonzalez, J. S. (2012) · Springer eBooks · doi:10.1007/978-0-85729-751-8_2 · Cited by 43
Yap, J. M., Tantono, N., Wu, V. X., & Klainin‐Yobas, P. (2021) · Journal of Telemedicine and Telecare · doi:10.1177/1357633x211058329 · Cited by 54
“21 It is assessed by the diabetes distress scale 22,23 and a score of three and above indicates that the individual has DD. 24 High levels of DD negatively affect self-care behaviour, treatment adherence and health outcomes; 21,25 while a reduction in DD can improve health outcomes such as HbA1c…”
BackgroundDiabetes-related emotional distress instruments: A systematic review of measurement properties
Lee, J., Lee, E., Kim, C., & Moon, S. H. (2015) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2015.07.004 · Cited by 39
Cummings, D. M., Lutes, L. D., Littlewood, K., DiNatale, E., Hambidge, B., Schulman, K., & Morisky, D. E. (2014) · Annals of Pharmacotherapy · doi:10.1177/1060028014536532 · Cited by 38
Psychometric properties of the Thai version of the Diabetes Distress Scale in diabetic seniors
Thanakwang, K., Thinganjana, W., & Konggumnerd, R. (2014) · Clinical Interventions in Aging · doi:10.2147/cia.s67200 · Cited by 37
Dobson, R., Whittaker, R., Jiang, Y., Shepherd, M., Maddison, R., Carter, K., Cutfield, R., McNamara, C., Khanolkar, M., & Murphy, R. (2016) · Trials · doi:10.1186/s13063-016-1305-5 · Cited by 36
“(PDF 82 kb) Abbreviations BCT: Behaviour Change Technique; BIPQ: Brief Illness Perception Questionnaire; DDS2: Diabetes Distress Scale – 2-item; DHB: District Health Board; ITT: intention-to-treat; QALY: Quality-adjusted Life Year; RCT: randomised controlled trial; SDSC: Summary of Diabetes Self-Care Activities; SEDM:…”
BackgroundMethodInfluentialEffects of Mindfulness on Psychological Distress and HbA1c in People with Diabetes
Pearson, S., Wills, K. E., Woods, M., & Warnecke, E. (2018) · Mindfulness · doi:10.1007/s12671-018-0908-1 · Cited by 38
“These worries and concerns are more specifically termed diabetes-related distress (Fisher et al. 2008b).”
Walker, R. J., Campbell, J. A., & Egede, L. E. (2019) · Journal of General Internal Medicine · doi:10.1007/s11606-019-05427-3 · Cited by 38
Identifying disease-specific distress in patients with inflammatory bowel disease
Woodward, S., Dibley, L. B., Combes, S., Bellamy, A., Clark, C., Czuber‐Dochan, W., Everelm, L., Kutner, S., Sturt, J. A., & Norton, C. S. (2016) · British Journal of Nursing · doi:10.12968/bjon.2016.25.12.649 · Cited by 35
Forsander, G., Bøgelund, M., Haas, J., & Samuelsson, U. (2016) · Pediatric Diabetes · doi:10.1111/pedi.12478 · Cited by 35
“A mean score of ≥3 (moderate distress) on the DDS-2 indicates problems with diabetes-related distress.(29) We also included the regimen-related distress subscale, which was included in order to highlight potential issues specific to the selfcare of diabetes.”
BackgroundMethodInfluentialMinimally Disruptive Medicine for Patients with Diabetes
Serrano, V., Spencer‐Bonilla, G., Boehmer, K. R., & Montori, V. M. (2017) · Current Diabetes Reports · doi:10.1007/s11892-017-0935-7 · Cited by 35
Metadata
- Authors
- Fisher, L., Glasgow, R. E., Mullan, J. T., Skaff, M. M., & Polonsky, W. H.
- Affiliations
- University of California, San Francisco (US)
- Kaiser Permanente (US)
- Venue
- The Annals of Family Medicine
- Publisher
- Annals of Family Medicine
- Published
- 2008-05-01
- Volume
- 6
- Issue
- 3
- Pages
- 246-252
- ISSN
- 1544-1709 (ISSN-L)
- 1544-1717
- PMC
- PMC2384991
- OpenAlex
- W1861477559
- Cited by
- 474
- References
- 14
- Citations by year
- 2026: 28 · 2025: 29 · 2024: 43 · 2023: 31 · 2022: 42 · 2021: 46 · 2020: 36 · 2019: 30 · 2018: 32 · 2017: 25 · 2016: 26 · 2015: 33 · 2014: 22 · 2013: 18 · 2012: 9
- FWCI
- 5.46
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Locations
- The Annals of Family Medicine (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- University of California, San Francisco
- National Institute of Diabetes and Digestive and Kidney Diseases (DK-061937, DK062732, R01DK061937, R01DK062732)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Health Sciences › Nursing › Research and Theory › Health Education and Validation
- Keywords
- diabetes distress, screening tool, type 2 diabetes, Diabetes Distress Scale, brief screening, psychometric properties, HbA1c, non-HDL cholesterol, physical activity, diet, emotional burden, disease management
- MeSH terms
- Aged, Depression, Major Depressive Disorder, Diabetes Mellitus, Type 2, Female, Glycated Hemoglobin, Humans, Lipoproteins, Male, Mass Screening, Middle Aged, Psychometrics, Self Care, Sensitivity and Specificity, Stress, Psychological, Comorbidity, Sickness Impact Profile
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