DIABETICMedicine

DOI: 10.1111/dme.13448

Systematic Review or Meta-analysis

The prevalence of diabetes-specific emotional distress in
people with Type 2 diabetes: a systematic review and
meta-analysis

N. E. Perrin1 , M. J. Davies1 , N. Robertson2, F. J. Snoek3 and K. Khunti1

1
Diabetes Research Centre, 2School of Psychology, College of Medicine, Biological Sciences and Psychology, University of Leicester, Leicester, UK and
3
Department of Medical Psychology, VU University Medical Centre, Academic Medical Centre Amsterdam, the Netherlands

Accepted 8 August 2017

Abstract
Aims Psychological comorbidity, such as depression and/or diabetes-specific emotional distress (diabetes distress), is
widespread in people with Type 2 diabetes and is associated with poorer treatment outcomes. Although extensive
research into the prevalence of depression has been conducted, the same attention has not been given to diabetes distress.
The aim of this systematic review was to determine the overall prevalence of diabetes distress in people with Type 2
diabetes.
Methods Seven databases were searched to identify potentially relevant studies; eligible studies (adult population
aged > 18 years with Type 2 diabetes and an outcome measure of diabetes distress) were selected and appraised
independently by two reviewers. Multiple fixed- and random-effects meta-analyses were performed to synthesize the
data; with primary analyses to determine the overall prevalence of diabetes distress in people with Type 2 diabetes, and
secondary meta-analyses and meta-regression to explore the prevalence across different variables.
Results Fifty-five studies (n = 36 998) were included in the meta-analysis and demonstrated an overall prevalence of
36% for diabetes distress in people with Type 2 diabetes. Prevalence of diabetes distress was significantly higher in
samples with a higher prevalence of comorbid depressive symptoms and a female sample majority.
Conclusions Diabetes distress is a prominent issue in people with Type 2 diabetes that is associated with female gender
and comorbid depressive symptoms. It is important to consider the relationship between diabetes distress and depression,
and the significant overlap between conditions. Further work is needed to explore psychological comorbidity in Type 2
diabetes to better understand how best to identify and appropriately treat individuals.
Diabet. Med. 34, 1508–1520 (2017)

demands of self-management required through adherence to

Introduction
Psychological comorbidity is high in people with Type 2
diabetes with extensive research demonstrating that ~ 30%
of patients experience depressive affect [1–3]. More recently
linked to Type 2 diabetes is diabetes-specific emotional
distress (diabetes distress), which encapsulates a much wider
affective experience than depression, constituting distinctive
emotional concerns within the ‘spectrum of patient experi-
ence’ for those living with a progressive and chronic
condition [4–7]. Diabetes distress refers to psychological
distress specific to living with diabetes and can encompass a
wide range of emotions, such as feeling overwhelmed by the
Correspondence to: Nicola E. Perrin. E-mail: n.e.perrin@gmail.com
diet, exercise and medication prescriptions. People with Type
2 diabetes may worry and ruminate about existing or future
complications, hold concerns about existing comorbidities,
be fearful of hypoglycaemia and harbour feelings of guilt or
shame, notably in relation to obesity or lifestyle [8,9].
Both depression and diabetes distress have been shown to
impact negatively in Type 2 diabetes through poor adherence
and reduced self-care [10–12]. Although depression and
diabetes distress are correlated conditions, research has
drawn a distinction between the two conditions suggesting
that diabetes distress is more widespread than depression
[13]. In addition, the literature suggests that diabetes distress
has a greater impact upon, and is more closely associated
with, diabetes self-management and diabetes-related

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 Systematic Review or Meta-analysis
behavioural and biomedical outcomes than depression. Most
notably, there appears to be an effect of diabetes distress on
HbA1c, whereas the impact of depression appears to be
equivocal [9,14–18]. A study by Fisher et al. [19] looking
specifically at the relationships between depression, diabetes
distress and HbA1c demonstrated that only diabetes distress,
and not major depressive disorder or depressive symptoms,
held cross-sectional and time-varying longitudinal relation-
ships to HbA1c, highlighting the importance of exploring the
concept of diabetes distress in this patient population.
A large proportion of research combines Type 1 and Type
2 diabetes populations when exploring diabetes distress,
however, this can be problematic because the way in which
diabetes distress manifests in the two populations may be
contextually different; such as fear of hypoglycaemia being a
more prominent fear in patients with Type 1 diabetes, or
feelings of guilt/shame being more prominent in patients with
Type 2 diabetes. The two validated scales used to assess
diabetes distress are the Problem Areas in Diabetes (PAID)
scale [20] and the Diabetes Distress Scale (DDS) [21]. The
PAID can be used for both Type 1 and Type 2 diabetes,
whereas the DDS offers a more comprehensive assessment, to
overcome psychometric limitations of the PAID, and is
specifically for people with Type 2 diabetes. It has previously
been emphasized that the information collected from patients
with Type 1 diabetes using the PAID scale would likely differ
from that found in people with Type 2 diabetes or a mixed
Type 1/Type 2 diabetes population [22], with leading authors
recently developing a separate DDS scale for people with
Type 1 diabetes, the T1-DDS [23].
To date, there has been no systematic review and meta-
analysis looking specifically at the prevalence of diabetes
distress in people with Type 2 diabetes only. The current
review sought to address this gap in the literature and
provide novel data on the prevalence of diabetes distress in
people with Type 2 diabetes, acknowledging the need to
assess this separately from individuals with Type 1 diabetes
to be able to give greater clarity of understanding and
extrapolation of findings to further research and clinical
practice.
Methods
Search strategy and selection
Bibliographic databases were searched using a combination
of free-text and medical subject heading (MeSH)/Thesaurus
terms, including EMBASE (1974 to 2016 week 44), MED-
LINE (1946 to 2016 week 44), PSYCINFO (1954 to 2016),
CINAHL (1993 to 2016), The Cochrane Library, the
Applied Social Sciences Index and Abstracts (ASSIA) (all
dates) and SCOPUS (all years to present). The search strategy
was circulated to members of the project team (KK, FS, NR,
MD) to advise on any further potential terms and these were
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DIABETICMedicine
added to the search. The finalized search (Fig. S1) for this
review was conducted on 5 November 2016.
The inclusion and exclusion criteria for this review were
developed alongside the review question using the PICOS
(participants, interventions, comparisons, outcomes, and
study design) approach [24]. The criteria were deliberately
broad, focusing only on ‘participants’ and ‘outcome’, to
capture as many studies as possible within the diabetes
distress literature since this is a relatively new field of study
and data were limited. Studies were selected, regardless of
methods, if they reported a baseline outcome measure of
diabetes distress within an adult population (≥ 18 years)
with Type 2 diabetes. For studies in which both Type 1 and
Type 2 diabetes populations were present, studies with a
majority of Type 2 diabetes (≥ 70%) were included. To
ensure external validity, experimental studies were included
if samples were from varied populations and platforms and
adopted broad inclusion criteria (Type 2 diabetes and adult
age). Studies were excluded if they were not reported in the
English language.
Two reviewers (NP, SB) independently assessed abstracts
and titles for eligibility and retrieved potentially relevant
articles using a shared paper-selection form developed
specifically for purpose to facilitate mutual understanding
(Fig. S2). The reviewers then met to discuss any differences in
opinion, which were resolved through discussion; there were
few instances where this occurred (< 5%) and no require-
ment for a third reviewer.
Data extraction
The main outcome measure to be extracted was a measure of
diabetes distress, taken as the number and percentage of the
overall population scoring over the threshold for significant
distress, dependent on the measure used. For studies report-
ing the PAID scale as their outcome measure, the cut-off
point was set at 40 as this is deemed high and has
discriminative validity [25,26]. For studies reporting the
PAID-5, a short-form version of the PAID, the cut-off was
≥ 8 [27]. For studies using the DDS, where the total is taken
as an average, rather than cumulatively, with moderate
distress considered as 2.0–2.9, the cut-off was ≥ 2 for the
purposes of this review [28]. Further data extracted included:
study design, outcome measure used, study location and
year, sample size, distribution, population demographics,
biomedical outcomes such as HbA1c and BMI, and comorbid
depression scores. Data was extracted by one reviewer (NP)
using a standardized form in Microsoft Excel (version
14.2.3) (Fig. S3). Where the primary outcome (diabetes
distress) data were missing, incomplete or unclear, study
authors were contacted for additional data and/or clarifica-
tion. If authors were unreachable due to out of date contact
information or did not respond then studies were excluded
from the final analyses.
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DIABETICMedicine Prevalence of diabetic-specific emotional distress in Type 2 diabetes  N. E. Perrin et al.
Study quality
Study quality was assessed using previously established
guidelines for the critical appraisal and scoring of health
research literature for the prevalence or incidence of a health
problem and adapting these specifically to the prevalence of
diabetes distress [29] (Table S1). The guidelines propose
three broad areas of exploration to determine the validity of
the study methods, the interpretation of the results and the
applicability of the results. Each study was appraised to
examine the appropriateness of design and sampling,
whether the sample size was adequate (n ≥ 300), whether
the measures were standardized and recorded without bias, if
adequate response rates were seen (≥ 70%), if prevalence
scores were reported with confidence intervals, and whether
the study subjects and setting were representative of the
current research question. A maximum score of eight was
available with study strength margins defined as ‘poor’
(scores of 1 or 2), ‘moderate–poor’ (scores of 2 or 4),
‘moderate–strong’ (scores of 5 or 6) and ‘strong’ (scores of 7
or 8).
Meta-analyses
The primary outcome was the total number of participants
and number of participants demonstrating significant levels
of diabetes distress, which we analysed using ‘metaprop’, a
statistical program implemented to perform meta-analyses of
proportions [30] in STATA (version 14.1). Metaprop deliv-
ers both fixed and random effects pooled estimates and we
used the Freeman–Tukey double arcsine transformation to
stabilize the variances [31]. Heterogeneity was assessed using
an I2 statistic to establish whether variations between studies
included in the meta-analyses were due to chance. The value
is expressed as a percentage of the total variation across
studies that is attributed to heterogeneity rather than chance,
which was quantified as low (25%), moderate (50%) and
high (75%) using tentative cut-off points suggested by
previous authors [32]. Publication bias was assessed using
Egger’s test [33] and a funnel plot.
Secondary random-effects meta-analyses were conducted
to determine and compare the prevalence of diabetes distress
and to identify potential sources of heterogeneity using meta-
regression analyses across the following variables: diabetes
distress scale used (DDS, PAID and PAID-5); study location
(region); population culture (eastern, western); mean age of
participants (30–39, 40–49, 50–59, 60–69, 70–79 years);
gender majority (≥ 50% female, ≥ 50% male); ethnicity
majority (≥ 50% white, ≥ 50% non-white); mean BMI
(≤ 30, ≥ 30); mean HbA1c [53.0–62.8 mmol/mol (7.0–
7.9%), 63.9–73.8 mmol/mol (8.0–8.9%), 74.9–84.7 mmol/
mol (9.0–9.9%), 107.7–117.5 mmol/mol (12.0–12.9%)];
mean years since diagnosis of Type 2 diabetes (2.0–3.9,
4.0–5.9, 6.0–7.9, 8.0–9.9, 10.0–11.9, 12.0–13.9, 14.0–15.9);
percentage of diabetes-related complications and/or
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comorbidities (10–19, 20–29, 30–39, 40–49, 50–59, 60–69,
70–79, 80–89, 90–99); and comorbid depressive symptoms
(0–9%, 10–19%, 20–29%, 30–39%, 40–49%, 50–59%, 60–
69%). All available data were extracted and meta-regression
variables were determined a posteriori once sufficient avail-
able data were determined.
Owing to varied reporting of complications and/or comor-
bidities across studies, careful consideration was given to
data inclusion within the analysis. Twenty-nine studies
reported data for complications and/or comorbidities, with
terms used interchangeably across studies. The current
reporting of ‘comorbidities and/or complications’ is defined
as physical conditions only. Studies that did not state
whether their data pertained to physical or psychological
conditions were excluded from the analysis. Where possible,
meta-regression analyses were performed for individual
comorbid conditions, with sufficient data available for
hypertension, dyslipidaemia, retinopathy, heart disease,
neuropathy, nephropathy and foot ulcers. Study location
regions were grouped into the six regions articulated by the
World Health Organization [34]: Americas, Eastern Mediter-
ranean, Western Pacific, Southeast Asia, European, Africa.
Regarding culture, populations were split into either Eastern
or Western cultures; Western cultures were defined as those
developing from Europe and their historic expansion into the
Americas and Australasia.
Results
Figure 1 demonstrates the study selection process. Searches
generated 6048 citations, of which 3105 titles and abstracts
were screened for eligibility once duplicates were removed.
Of these, 283 potentially relevant studies were selected for
full text retrieval, of which 159 were eligible for the review,
and 55 were eligible and provided sufficient data to be
included within the meta-analyses (Refs e1–e54, Doc. S1).
One paper (Ref. e8, Doc. S1) reported data for two separate
studies and these were separated for the analyses.
Studies included in the meta-analyses are summarized in
Table 1. Diabetes distress was measured using either the
PAID (n = 25), the PAID-5 short-form version (n = 9) or the
DDS (n = 21).
Studies were conducted within the last 16 years, with data
collected from the USA (n = 20), Canada (n = 7), the
Netherlands (n = 5), Australia (n = 6), China (n = 3), Sin-
gapore (n = 2), France (n = 1), Germany (n = 1), Italy
(n = 1), India (n = 1), Iran (n = 1), Japan (n = 1), Malaysia
(n = 1), Norway (n = 1) Serbia (n = 1), Slovenia (n = 1) and
South Africa (n = 1); there was one multinational study.
Most studies in this review adopted an observational
design (n = 43), with 12 experimental studies. Samples sizes
within the studies ranged from 21 to 8596. The average age
of participants in the studies was 57.4 years (range: 32.3–
70.0 years), with an even split of gender (51% men). The
minority of people (38%) were of white ethnicity.
ª 2017 Diabetes UK
 Systematic Review or Meta-analysis
FIGURE 1 Consort flow-diagram demonstrating the study selection process in a systematic review and meta-analyses to determine the prevalence of
diabetes-specific emotional distress in people with Type 2 diabetes.
Participants had been diagnosed with Type 2 diabetes for an
average of 9.7 years (range: 2.9–15.6 years) and had an
average HbA1c of 67.2 mmol/mol (8.3%) (range: 53.0 to
107.7 mmol/mol; 7.0–12.0%). The average BMI in partic-
ipants was 31.7 kg/m2 (range 26.5–36.8 kg/m2).
Study quality assessment (Table S1) demonstrated a mean
score of 5.2 of 8, with the majority of studies (n = 36,
64.2%) scoring ‘moderate–strong’. The remaining studies
consisted of three scoring as ‘poor’ (5.4%), nine scoring as
‘poor–moderate’ (16.1%) and eight scoring as ‘strong’
(14.3%).
Fifty-five studies, with a total of 36 998 participants,
reported the number/percentage of participants demonstrat-
ing significant diabetes distress and were included in fixed-
and random-effects meta-analyses to determine the overall
prevalence of diabetes distress in people with Type 2 diabetes
(Fig. 2).
The overall prevalence of diabetes distress was 36%;
random-pooled effect size (ES) 0.360 [95% confidence
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interval (95% CI) 0.308, 0.413], fixed-pooled ES 0.356
(95% CI 0.351, 0.361). Heterogeneity was shown to be very
high with I2 = 99.03, with meta-regression analyses identi-
fying potential confounders in gender distribution
(P = 0.011) and comorbid depressive symptoms
(P = 0.009); finding prevalence to be increased in studies
with a female sample majority and in samples with comorbid
depressive symptoms (Table 2). Eggers test (P = 0.119)
suggested that publication bias was absent. The funnel plot,
however, demonstrated asymmetry, with a greater represen-
tation of studies where higher diabetes distress proportions
were seen, indicating potential for bias (Fig. S4).
Discussion
Key findings
This comprehensive meta-analysis of 55 studies showed that
the overall prevalence of diabetes distress using established
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 Table 1 Overview of studies included in the meta-analyses to determine the prevalence of diabetes-specific emotional distress in people with Type 2 diabetes

1512
Mean Mean
Mean age Ethnicity Gender HbA1c HbA1c Mean Mean
Study* Location Design N (years) (% C) (% male) (mmol/mol) (%) % DD (SD) DD Measure % DS (SD) DS Measure
DIABETICMedicine

Aikens et al., USA Cross-sectional/ 303 66.60 92.90 97.00 NR NR 4.00 31.20 (13.10) PAID 30.20 2.50 (2.37) CES-D
2014 [e1] longitudinal
Aikens 2012, [e2] USA Observational 253 57.30 45.00 50.00 59.6 7.60 21.00 22.10 (19.00) PAID 50.00 05.60 (4.70) PHQ-9
Ang Co et al., Singa-pore Longitudinal 213 45.00 0 63.40 67.2 8.30 31.92 29.03 (21.91) PAID NR NR NR
2015 [e3]
Baek et al., 2014 USA Cross-sectional 119 56.30 25.40 36.10 62.8 7.90 27.70 2.30 (1.20) DDS NR NR NR
[e4]
Baradaran et al., Iran Cross-sectional 185 56.06 0 48.00 64.3 8.03 35.00 NR PAID 43.20 NR C.I.
2013 [e5]
Baumeister et al., Ger-many RCT 145 57.30 NR 63.10 NR NR 10.15 NR PAID 41.50 NR PHQ-9
2014 [e6]
Beverly et al., USA RCT 134 59.10 71.60 48.50 68.3 8.40 27.23 34.10 (21.70) PAID NR 49.70 (10.40) BSI
2013 [e7]
Browne et al., Australia RCT 125 56.00 NR 68.00 76.3 9.13 24.00 27.18 (20.04) PAID NR NR NR
2016 [e8]
Browne et al., Australia Cross-sectional 78 63.00 NR 47.00 64.7 8.07 24.00 25.41 (19.84) PAID NR NR NR
2016 [e8]
Browne et al., Australia Cross-sectional 149 32.33 NR 38.20 NR NR 63.00 9.41 (4.85) PAID-5 NR NR NR
2012 [e9]
Burns et al., 2016 Canada Cross-sectional/ 1742 60.51 93.00 50.90 NR NR 22.40 NR DDS 5.90 NR PHQ-9
[e10] propspective
Carper et al., USA Cross-sectional 146 56.01 82.00 57.50 66.7 8.25 79.5 2.87 (1.09) DDS 56.80 DDS C.I.
2012 [e11]
Chen et al., 2013 China Uncontrolled 1200 NR 0 100.0 NR NR 65.50 NR PAID 28.00 NR CES-D
[e12] case-series
Chesla et al., USA Uncontrolled 178 64.45 0 41.00 54.9 7.17 71.60 2.59 (2.38) DDS 48.00 18.06 (11.79) CES-D
2013 [e13] case-series
Chew et al., 2015 Malaysia Cross-sectional 262 NR NR NR NR NR 09.20 NR DDS NR NR NR
[e14]
Delahanty et al., USA Cohort 815 NR 85.33 51.00 NR NR 15.43 18.70 (20.40) PAID NR NR NR
2007 [e15]
Fisher et al., 2010 USA Cross-sectional 463 58.80 72.00 48.50 65.0 8.10 51.30 NR DDS 15.30 NR PHQ-8
[e16]
Gariepy et al., Canada Cross-sectional 600 58.10 NR 46.30 NR NR 23.00 1.60 (0.70) DDS NR NR NR
2013 [e17]
Holmes-Truscott Australia Cross-sectional 261 62.00 NR 60.50 74.9 9.00 15.00 19.70 (18.20) PAID 15.00 4.50 (4.90) PHQ-9
et al., 2016 [e18]
Holmes-Truscott Australia Cross-sectional 313 57.00 NR 57.00 NR NR 29.00 1.80 (1.00) DDS 24.00 6.00 (5.60) PHQ-9
et al., 2016 [e19]
Ikeda et al., 2014 Japan Cross-sectional 199 60.45 21.71 58.50 59.6 7.60 33.00 28.57 (19.95) PAID NR NR NR
[e20]
Jansen et al., Nether-lands Prospective 65 60.00 95.00 64.00 73.8 8.90 73.85 10.00 (1.40) PAID NR NR NR
2014 [e21] observational
Johnson et al., Canada Cross-sectional 2040 64.40 90.80 54.80 NR NR 07.90 NR PAID-5 3.00 NR PHQ-8
2016 [e22]
Prevalence of diabetic-specific emotional distress in Type 2 diabetes  N. E. Perrin et al.

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 Table 1 (Continued)

Mean Mean
Mean age Ethnicity Gender HbA1c HbA1c Mean Mean
Study* Location Design N (years) (% C) (% male) (mmol/mol) (%) % DD (SD) DD Measure % DS (SD) DS Measure

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Karlsen et al., Norway Cross-sectional 378 58.10 100 54.20 54.1 7.10 22.00 26.00 (18.00) PAID NR NR NR
2012 [e23]
LeBron et al., USA Cross-sectional 157 52.60 0 29.30 NR NR 23.31 25.00 (1.76) PAID 13.41 5.07 (5.12) PHQ-9
2014 [e24]
McEwen et al., USA Uncontrolled 21 53.71 NR 19.00 61.6 7.79 19.00 2.14 (1.70) DDS NR NR NR
2010 [e25] case-series
Nichols et al., USA Cross-sectional 924 35.10 NR NR 63.4 7.95 35.17 NR PAID NR NR NR
Systematic Review or Meta-analysis

2000 [e26]
Nicolucci et al., Multi-national Cross-sectional 8596 57.00 NR 52.60 NR NR 44.60 35.20 (24.20) PAID 25.50 NR WHO-5
2013 [e27]
Park et al., 2015 USA Cross-sectional 155 55.70 40.60 28.40 57.4 7.40 54.19 2.33 (1.04) DDS 24.50 NR Self-report
[e28]
Pintaudi et al., Italy Cross-sectional 2374 65.00 NR 59.90 60.7 7.70 60.20 NR PAID-5 NR NR NR
2015 [e29]
Primozic et al., Slovenia Cross-sectional 98 63.74 NR 49.00 56.3 7.30 13.20 15.09 (12.78) PAID NR 10.48 (7.87) HDI
2012 [e30]
Ramkisson et al., South Africa Cross-sectional 401 53.70 06.00 39.40 107.9 12.02 44.00 2.10 (1.10) DDS NR NR NR
2016 [e31]
Reach et al., 2015 France Cross-sectional 500 NR NR 55.00 NR NR 44.00 NR PAID-5 28.00 NR WHO-5
[e32]
Rogvi et al., 2012 Nether-lands Cross-sectional 2045 64.30 NR 65.00 59.6 7.60 29.05 NR PAID-5 NR NR NR
[e33]
Schiøtz et al., Nether-lands Cross-sectional 2572 60.50 NR 66.00 58.5 7.50 26.00 NR PAID-5 NR NR NR
2011 [e34]
Sekhar et al., India Cross-sectional 546 55.44 0 56.00 NR NR 53.00 NR DDS NR NR NR
2013 [e35]
Sidhu and Tang, Canada Cross-sectional 41 67.00 0 27.00 NR NR 42.50 NR DDS 15.00 NR PHQ-9
2016 [e36]
Sinclair et al., USA RCT 65 53.83 0 37.50 84.3 9.86 67.10 28.10 (27.11) PAID NR NR NR
2013 [e37]
Smith et al., 2013 USA Cross-sectional 1787 60.55 NR 48.50 NR NR 22.50 NR DDS 13.38 NR NR
[e38]
Spencer et al., USA Cross-sectional 180 56.63 0 25.55 74.1 8.93 25.10 23.93 (21.81) PAID NR NR NR
2006 [e39]
Stankoviv et al., Serbia Cross-sectional 90 55.75 NR 34.65 73.8 8.90 67.80 47.97 (15.83) PAID 51.10 10.54 (7.86) PHQ-9
2011 [e40]
Stoop et al., 2014 Nether-lands Cross-sectional 1300 65.00 94.00 55.00 53.3 7.03 10.00 14.06 (17.45) PAID NR NR NR
[e41]
Tang et al., 2015 USA RCT 106 56.30 0 35.00 62.8 7.90 39.40 5.35 (1.49) DDS NR NR NR
[e42]
Thom et al., 2013 USA RCT 299 55.79 10.75 47.80 85.7 9.99 60.96 2.41 (0.97) DDS NR NR NR
[e43]
Vallis et al., 2016 Canada Cross-sectional 500 54.00 NR 52.00 NR NR 29.20 28.18 (23.84) PAID-5 12.80 58.17 (22.57) WHO-5
[e44]

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Table 1 (Continued)

Mean Mean
Mean age Ethnicity Gender HbA1c HbA1c Mean Mean
Study* Location Design N (years) (% C) (% male) (mmol/mol) (%) % DD (SD) DD Measure % DS (SD) DS Measure

Van Vugt et al., Nether-lands Pre–post test 297 NR 96.90 51.50 53.0 7.00 13.20 NR PAID-5 NR NR NR
2016 [e45] observational
Venkataraman Singa-pore Cross-sectional 203 45.00 0 64.00 67.2 8.30 32.00 28.80 (21.90) PAID NR NR NR
et al., 2016 [e46]
Wardian and Sun, USA Cross-sectional 267 57.97 56.00 44.00 NR NR 59.93 2.40 (0.99) DDS NR NR NR
2014 [e47]
Welch et al., 2015 USA RCT 399 55.00 0 40.10 74.3 8.95 56.70 55.44 (31.58) PAID-5 36.95 NR PHQ-9
[e48]
Welch et al., 2011 USA RCT 46 55.82 NR 35.05 72.3 8.77 50.85 49.68 (23.82) PAID 66.10 NR PHQ-9
[e49]
Wong et al., 2015 Canada Cross-sectional 148 NR NR NR NR NR 39.00 NR DDS 12.00 NR PHQ-9
[e50]
Wycherley et al., Australia RCT 84 56.10 NR 58.30 57.7 7.43 36.80 31.90 (19.30) PAID NR NR NR
2014 [e51]
Zhang et al., China Cross-sectional 200 59.60 0 48.00 NR NR 64.00 NR DDS NR NR NR
2013 [e52]
Zhu et al., 2016 China Cross-sectional 397 56.33 58.90 58.90 82.7 9.72 33.80 NR DDS NR NR NR
[e53]
Zulman et al., USA Cross-sectional 1834 70.00 76.00 48.00 NR NR 62.00 NR PAID 19.00 NR CES-D
2012 [e54]

*
References are given in Supporting Information Doc. S1. C, Caucasian; CES-D, Center for Epidemiological Studies Depression Scale; DS, depressive symptoms; DD, diabetes-specific emotional
distress; DDS, Diabetes Distress Scale, HADS, Hospital Anxiety and Depression Scale; NR, not reported.
Prevalence of diabetic-specific emotional distress in Type 2 diabetes  N. E. Perrin et al.

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FIGURE 2 Forest-plot demonstrating the findings of the primary meta-analyses to determine overall prevalence of diabetes-specific emotional distress
in people with Type 2 diabetes. CI, confidence interval; References are given in Supporting Information Doc. S1.

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DIABETICMedicine Prevalence of diabetic-specific emotional distress in Type 2 diabetes  N. E. Perrin et al.

Table 2 Results of sub-group meta-analyses and meta-regression to explore the prevalence of diabetes-specific distress across different variables

Meta-analyses Meta-regression

Prevalence Weight
Variables NS (%) ES 95% CI % Co-efficient SE P-value 95% CI

Outcome measure DDS 21 42 0.420 0.343 0.498 37.97

PAID 25 33 0.332 0.246 0.417 45.36 –0.040 0.038 0.298 –0.115 0.036
PAID-5 9 37 0.365 0.225 0.504 16.67
Study year 2015–2016 21 34 0.338 0.245 0.431 38.28
2013–2014 19 40 0.395 0.297 0.492 34.62 –0.004 0.009 0.651 –0.023 0.015
2011–2012 10 43 0.432 0.309 0.554 18.14
2010 and earlier 5 30 0.296 0.154 0.439 8.97
Study location Americas 27 38 0.383 0.304 0.463 48.77
Eastern Mediterranean 1 35 0.350 0.285 0.421 1.82
Western Pacific 13 36 0.355 0.228 0.482 23.66
Southeast Asia 1 53 0.530 0.488 0.572 1.85 0.018 0.023 0.441 –0.028 0.064
Europea 11 33 0.332 0.215 0.449 20.19
Africa 1 44 0.440 0.392 0.489 1.84
NA - Multinational 1 45 0.446 0.345 0.457 1.87
Study location Western 46 36 0.357 0.301 0.414 83.47
culture Eastern 8 44 0.436 0.321 0.552 14.66 –0.055 0.069 0.433 –0.194 0.845
NA - Multinational 1 45 0.446 0.345 0.457 1.87
Age (years) 30–39 2 39 0.390 0.361 0.418 3.95
40–49 2 32 0.320 0.275 0.364 3.94
50–59 30 40 0.401 0.348 0.454 58.41 –0.005 0.004 0.202 –0.013 0.003
60–69 16 28 0.283 0.200 0.365 31.68
70–79 1 62 0.620 0.598 0.642 2.02
Gender Female 24 45 0.447 0.366 0.528 45.51
majority (%) Male 28 32 0.317 0.244 0.389 54.49 –0.139 0.053 0.011 –0.245 –0.033
Ethnicity White 13 34 0.342 0.230 0.455 39.71
majority (%) Black and 20 44 0.441 0.366 0.516 60.29 –0.108 0.074 0.154 –0.259 0.043
minority ethnic
BMI < 30 8 32 0.318 0.181 0.454 26.41
> 30 23 43 0.425 0.352 0.498 73.59 –0.015 0.011 0.189 0.008 0.038
HbA1c 53.0–62.8 (7.0–7.9) 15 32 0.315 0.199 0.431 45.56
mmol/mol (%) 63.8–73.8 (8.0–8.9) 11 48 0.481 0.373 0.590 33.18
74.9–84.7 (9.0–9.9) 6 37 0.373 0.208 0.537 18.17 0.059 0.033 0.082 –0.008 0.125
107.7–117.5 (12.0–12.9) 1 44 0.440 0.392 0.489 3.08
Years diagnosed 2.00–3.99 1 63 0.630 0.550 0.703 2.74
with Type 2 4.00–5.99 2 26 0.261 0.243 0.280 5.69
diabetes 6.00–7.99 6 41 0.441 0.307 0.576 16.33
8.00–9.99 13 35 0.354 0.255 0.454 36.21 –0.008 0.011 0.464 –0.032 0.015
10.00–11.99 5 42 0.420 0.264 0.577 13.75
12.00–13.99 5 39 0.389 0.135 0.644 13.86
14.00–15.99 4 35 0.346 0.158 0.533 11.42
Comorbidities/ 10–19 1 74 0.738 0.621 0.830 3.97
complications
Overall (%) 20–29 1 21 0.210 0.164 0.264 4.18
30–39 3 48 0.475 0.307 0.644 12.62
40–49 4 25 0.253 0.109 0.398 16.74
50–59 2 23 0.232 0.195 0.269 8.29 –0.001 0.002 0.973 –0.005 0.005
60–69 3 41 0.411 0.052 0.770 12.51
70–79 7 39 0.396 0.230 0.561 29.30
80–89 2 23 0.227 0.209 0.246 8.38
90–100 1 68 0.678 0.576 0.466 4.01
Condition specific Hypertension 7 –0.002 0.005 0.663 –0.017 0.012
Dyslipidaemia 5 –0.000 0.005 0.994 –0.020 0.020
Retinopathy 11 0.008 0.006 0.225 –0.006 0.023
Heart disease 12 0.002 0.003 0.515 –0.004 0.008
Nephropathy 10 0.019 0.013 0.199 –0.013 0.050
Neuropathy 12 0.004 0.003 0.247 –0.003 0.011
Foot ulcers 4 0.059 0.007 0.075 –0.029 0.146
Sexual dysfunction 4 0.009 0.012 0.619 –0.150 0.167
Comorbid 0–9 2 17 0.117 0.107 0.127 9.30
depressive 10–19 8 32 0.319 0.165 0.473 36.37
symptoms (%) 20–29 4 48 0.477 0.362 0.591 18.29
30–39 2 13 0.130 0.110 0.150 9.24 0.007 0.002 0.009 0.002 0.012

1516 ª 2017 Diabetes UK

 Systematic Review or Meta-analysis
Table 2 (Continued)
Meta-analyses
Prevalence
Variables NS (%) ES
40–49 2 54
50–59 3 56
60–69 1 50
CI, confidence interval; DDS, Diabetes Distress Scale; ES, effect size; PAID, Problem Areas in Diabetes Scale;
cut-off scores in people with Type 2 diabetes was 36%, with
secondary analyses identifying gender (P = 0.010) and
comorbid depressive symptoms (P = 0.008) as significant
factors affecting prevalence.
Strengths and limitations
This is the first known systematic review and meta-analyses
of the existing literature to determine the prevalence of
diabetes distress in a solely Type 2 diabetes population. As
such, it provides novel information for a gap in the literature.
The methods used to carry out this review were robust,
adopting strategies to gain all relevant outcome data avail-
able, even when not reported.
Although it is a potential strength that this review is the
first of its kind, it meant that the data available were limited,
because the field of diabetes distress is a relatively new one.
This was further hindered by the vast majority of papers not
reporting the data required for the analyses, and despite
extensive efforts to contact authors for any missing data or to
clarify any discrepancies, this often proved unsuccessful,
either due to contact details no longer being valid and/or
receiving no reply.
There was high heterogeneity between studies, with
particular concern lying in the reporting of diabetes distress
and the scales used. A number of studies that reported DDS
scores conveyed the score as a cumulative rather than an
average, meaning that their results were dramatically higher
than the majority of studies. As such, if authors did not
respond to requests for an average score, these studies needed
to be excluded so as not to bias the results. Similarly, the
reporting of comorbid depressive symptoms/depression was
highly varied with 10 different scales reported, two studies
reporting diagnoses by clinical diagnostic interview and one
study merely stating the percentage that has ‘regular MD’
(major depression). Although further heterogeneity between
studies was evident in terms of study location and population
demographics, this was useful in terms of understanding the
prevalence of diabetes distress across variables.
Overall study quality demonstrated a moderate risk of
bias, with the majority of studies scoring as ‘moderate–
strong’. We observed a large proportion of negative counts
resulting from a lack of reporting, such as insufficient
ª 2017 Diabetes UK
DIABETICMedicine
Meta-regression
Weight
95% CI % Co-efficient SE P-value 95% CI
0.540 0.492 0.587 9.08
0.560 0.153 0.967 13.56
0.509 0.369 0.647 4.16
SE, standard error.
reporting of response rates or details of assessors. Further
points were lost due to 43.6% of studies having inadequate
sample sizes. The most prominent loss of points came from
prevalence rates not being reported with confidence intervals,
with the vast majority of studies either reporting diabetes
distress as n (%) or mean (SD). Nearly all studies clearly
specified and defined their eligibility criteria and recruited
from either a randomized or a whole population sample of
the same/similar populations. Having appraised each study,
we feel that for the purposes of the current findings, the
samples were representative of the target population and
while heterogeneity was high, this offered useful exploration
within our analyses.
Analyses to determine if publication bias was evident
offered inconsistent results. While the funnel plot shows
asymmetry, Egger’s test deemed that publication bias was
not present. It is possible that the distribution within the
funnel plot, namely an excess of studies to the right of the
plot, could suggest a bias in that studies with higher results of
diabetes distress are more likely to be published.
Surrounding evidence and implications
Elevated levels of diabetes distress appear to be widespread
with estimates given by leading authors varying between
18% and 35% [7,28] in combined Type 1 diabetes and Type
2 diabetes populations, with a recent systematic review and
meta-analysis looking into the prevalence of diabetes distress
in research populations demonstrating a prevalence of 22%
[35]. A study by Fisher et al. in 2008 explored the longitu-
dinal rates of affective disorders, including diabetes distress,
demonstrating an approximate point prevalence of 46% in
people with Type 2 diabetes [16]. The current findings
demonstrated a 36% prevalence of diabetes distress in people
with Type 2 diabetes, which is higher than the research
combining Type 1 diabetes and Type 2 diabetes populations
and could be indicative of a difference between how diabetes
distress manifests and presents in these populations.
Although research has shown that rates are similar when
appropriate type-specific scales are used, with a 42.1% point
prevalence and 54.4% incidence of diabetes distress in
people with Type 1 diabetes, and 46.2% and 54.3% in
people with Type 2 diabetes respectively [23]. The current
1517
DIABETICMedicine Prevalence of diabetic-specific emotional distress in Type 2 diabetes  N. E. Perrin et al.
study is the first systematic review and meta-analysis of
diabetes distress in Type 2 diabetes and highlights the
importance of understanding how diabetes distress manifests
in this population specifically.
The results demonstrated that diabetes distress was
significantly higher in samples with a majority of women
compared with samples with a majority of men. Previous
studies have recognized a link between female gender and
diabetes distress, as well as depression and anxiety, with
greater risk in women compared with men [13,16]. This
increased presence of expressed emotional difficulties in
women with Type 2 diabetes may be attributable to
differing social conventions regarding gender: men appear
less likely to seek help and/or admit distress due to a need
to appear capable or for fear of being emasculated by
showing weakness [36]. A further argument could be that
men may try to fulfil ‘masculine’ gender identities, such as
problem solving, which could encourage them to privilege
treatment advice to overcome their condition [37].
Although such stereotypes may be less prevalent in
younger cohorts, amongst older generations, who are
over-represented in the studies reviewed, these gender
identities may pertain and partially explain why emotional
difficulties appear less common in men. This reiterates a
need to take account of an individual’s personal presen-
tation and circumstance when approaching assessment of
well-being both psychologically and in terms of physiolog-
ical diabetes-related issues, to ensure the best identification
of issues to treat and offer appropriate management of
these.
Our findings also demonstrated a significant difference in
diabetes distress rates when accounting for the prevalence
of comorbid depression in the samples, with significantly
lower prevalence of diabetes distress in samples with low
to no prevalence of comorbid depression. This supports
existing research highlighting that diabetes distress and
depression are highly correlated constructs [38–43].
Research has emphasized concerns with poor recognition
in both depression [44–48] and diabetes distress [43,49],
with a substantial overlap between symptoms and presen-
tation of both conditions. It is important to consider when
assessing psychological status in people with Type 2
diabetes that these are different constructs that can either
coexist, occur in isolation, or present distinct from one
another.
Prevalence of diabetes distress appeared higher in studies
reporting the DDS compared with the PAID and the PAID-5
scales, although this difference was non-significant. It would
be advantageous for future research to explore this further to
see whether the increased prevalence scores seen with the
DDS vs. the PAID scale might be due to varying stringency in
their opposing criteria (40% vs. 20% thresholds), with our
findings corroborated by higher reported diabetes distress in
the USA, where the DDS is more predominantly used,
compared with Europe [26]. A recent study comparing the
1518
DDS and PAID acknowledged that although both scales are
excellent psychometric self-report measures, they bear fun-
damental differences in terms of the domains they address
[50]. For example, the authors noted that the PAID scale
encapsulates a broader range of emotional concerns than the
DDS, the latter encompassing factors more closely linked to
diabetes self-management. This could explain the differences
in prevalence between the measures found in the present
findings, because the scales themselves explore fundamen-
tally different aspects of diabetes distress. This also elucidates
concerns about the disparity in defining and assessing
diabetes distress; because there is no one-single definition
or diagnostic criterion for diabetes distress, this leaves open
further obstacles in properly identifying, and thus treating,
people with Type 2 diabetes who present with comorbid
psychological difficulties. This issue is further clouded when
considering the grouping of Type 1 diabetes and Type 2
diabetes together when exploring the notion of diabetes
distress. Although there is evidence to suggest that there are
no fundamental differences in reported diabetes-related
stressors between the two condition types using the PAID
scale [26], using specific scales developed for Type 1 and
Type 2 diabetes, such as the T1-DDS and T2-DDS, may
foster better understanding of the experience and care needs
of these individuals.
Conclusion
The findings of this review demonstrate that diabetes distress
is a prominent issue in people with Type 2 diabetes, and that
it is greater in groups with a female gender majority and with
higher prevalence of comorbid depressive symptoms. Depres-
sion and diabetes distress are highly related and both appear
to be under-recognized and inadequately treated in Type 2
diabetes. The findings of this review highlight the importance
of the identification and subsequent management of diabetes
distress and/or depression in people with Type 2 diabetes,
with particular priority given to the use of appropriate scales
and the interpretation of findings to allow for patient-centred
and suitably tailored care. Further work is required to
explore psychological comorbidity in people with Type 2
diabetes and gain better understanding of how best to
support them.
Funding sources
We acknowledge support from the National Institute for
Health Research Collaboration for Leadership in Applied
Health Research and Care – Leicestershire, Northampton-
shire and Rutland (NIHR CLAHRC – LNR), the Leicester
Clinical Trials Unit and the NIHR Leicester-Loughborough
Diet, Lifestyle and Physical Activity Biomedical Research
Unit which is a partnership between University Hospitals of
Leicester NHS Trust, Loughborough University and the
University of Leicester.
ª 2017 Diabetes UK
 Systematic Review or Meta-analysis
Competing interests
None declared.
Acknowledgements
We acknowledge Shaun Barber for his support as second
reviewer.
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Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Doc. S1. Supplementary references.
Figure S1. Example search strategy for a systematic review to
determine the prevalence of diabetes-specific emotional
distress in people with Type 2 diabetes.
Figure S2. Paper-selection form designed for mutual under-
standing during the first stage of appraisal in a systematic
review to determine the prevalence of diabetes-specific
emotional distress in people with Type 2 diabetes.
Figure S3. Data-extraction form used in a systematic review
to determine the prevalence of diabetes-specific emotional
distress in people with Type 2 diabetes.
Figure S4. Funnel plot with pseudo 95% confidence limits to
assess potential publication bias in meta-analysis to deter-
mine the prevalence of diabetes-specific emotional distress in
people with Type 2 diabetes.
Table S1. Results of quality assessment of studies included in
a meta-analysis to determine the prevalence of diabetes-
specific emotional distress in people with Type 2 diabetes.
ª 2017 Diabetes UK