Journal of Social Health and Diabetes

: 2018  |  Volume : 6  |  Issue : 1  |  Page : 4--7

Diabetes distress

Sanjay Kalra1, Komal Verma2, Yatan Pal Singh Balhara3,  
1 Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
2 Department of Psychology, Amity Institute of Behavioural and Allied Sciences, Amity University, Jaipur, Rajasthan, India
3 Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Sanjay Kalra
Department of Endocrinology, Bharti Hospital, Karnal, Haryana


How to cite this article:
Kalra S, Verma K, Balhara YP. Diabetes distress.J Soc Health Diabetes 2018;6:4-7

How to cite this URL:
Kalra S, Verma K, Balhara YP. Diabetes distress. J Soc Health Diabetes [serial online] 2018 [cited 2018 Dec 17 ];6:4-7
Available from:

Full Text

Diabetes distress (DD) is a psychological state, found in persons with diabetes and their caregivers. This is a state which causes significant emotional distress, however it fails to meet the diagnostic criteria for major depressive disorder (MDD). The 2017 Standards of Medical Care in Diabetes, published by the American Diabetes Association, mentions the need to assess and manage DD to improve self-care and glycemic control and reduce cardiovascular risk and all-cause mortality.[1]


DD has been defined in various ways. Kreider (2017) refers to DD as an emotional state where people experience feelings such as stress, guilt, or denial that arise from living with diabetes and the burden of self-management.[2] Gonzalez et al. (2011) describe DD as the unique, often hidden emotional burdens and worries that are part of the spectrum of patient experience when managing a severe, demanding chronic disease like diabetes.[3] Fisher et al. (2012) define DD as significant emotional reactions to the diagnosis, threat of complications, self-management demands, or unsupportive social structures surrounding diabetes.[4] DD, according to Fisher et al., (2012) refers to fears of complications, worries about hypoglycemia and the variety of stresses, strains, and concerns people with diabetes have on a day-to-day basis. Describing the term as such makes it more specific and alive to individuals who live with diabetes. He also highlights the existence of DD in family members who care for persons with diabetes.[5]

We define DD as an emotional response characterized by extreme apprehension, discomfort, or dejection, due to perceived inability to cope with the challenges and demands of living with diabetes. Our definition, mentioned above, draws from the conceptualization of DD as proposed by Fisher. [5],[6]


Community-based studies reveal that DD may occur in up to 45% of persons with type 2 diabetes mellitus. DD is more frequent in younger people, and in insulin-users. Other data suggest that 39% of Type 1 and 35% of Type 2 patients experience significant DD at any given time.[4],[6]


DD is part of living with diabetes experience. Self-perception of inadequacy and uncertainty, poor opinion of the accessibility and/or ability of the diabetes care professional, and dissatisfaction with social support are the main factors contributing to the DD [Table 1]. The risk of DD is higher during periods of change, as listed in [Table 2].{Table 1}, {Table 2}

 Symptomatology and Diagnosis

The symptoms of DD are similar to those of MDD, but are not severe enough to qualify as MDD. DD can be diagnosed using validated screening and diagnostic tools [Table 3].[2] These instruments differ in the number of items, ease of administration, and utility in different types of diabetes, treatment regimens, or stakeholders. It must be noted that diagnostic and screening tools for DD are different from those for MDD. Some of the core symptoms of DD are listed in [Table 4].{Table 3}, {Table 4}

 Differential Diagnosis

The differential diagnosis includes not only MDD,[7],[8] but also uncontrolled hyperglycemia. Comorbid endocrine/metabolic conditions such as hypothyroidism, hypogonadism, vitamin D deficiency, obesity, and obstructive sleep apnea should be ruled out before DD is diagnosed.[2] Nonendocrine comorbidities, including anemia, dyselectrolytemia, poor sleep hygiene, and poor physical condition are other causes which may lead to similar symptoms [Table 5].{Table 5}

 Clinical Impact

DD is associated with low self-efficacy, poor adherence to suggested lifestyle regimes, poor glycemic control, and complications such as dyslipidemia [Table 6].[6]{Table 6}


Management of DD is nonpharmacological in nature. The foundation of DD management is empathic and confidence-building communication by members of the diabetes care team. Up to 40% of persons with DD can improve without formal intervention.[9] Hence, a suggested strategy is “watchful waiting,” while promoting lifestyle modification [Table 7].{Table 7}

Management is based on the concept of “Diabetes therapy by the ear,” which includes listening to the patient, counseling,[10] and assisting in filtering nonscientific and irrational beliefs about the condition. Provision of diabetes education, self- management skills, coping skills training counseling and support is the best means of preventing, limiting and managing DD.

DD is often associated with change. Change is always associated with discomfort. One needs, therefore, to minimize the discomfort of change.[11] This can be done by involving the patient in a step-wise process of informed decision making and allowing choice as well as a review of such decisions [Table 8].{Table 8}

One must allow adequate contemplation of change, as per the 3 “I” strategy (inform, incubate, and initiate).[12] Positive motivation is an important aspect of therapy, which helps enhance acceptance of change. We suggest the 5 “I” Strategy as an approach to DD [Table 9]. This involves initiating discussion so as to identify possible stressors, informing the patient about methods to minimize DD, and helping incorporate positive coping mechanisms, so as to improve outcomes.{Table 9}

 Capacity Building

It helps to have a collaborative, inter-specialty approach to DD prevention and management. Diabetes care professionals need to develop certain basic biomedical as well as soft skills, to address DD properly [Table 10]. These include awareness of the condition and its differential diagnosis, ability to effectively communicate with the patient and offer appropriate interventions, as well as the foresight to refer to other health-care professionals when necessary.{Table 10}

Various acronyms such as CARES[13] and WATER[14] have been developed to help the diabetes care physician develop a patient-oriented approach and practice fruitful motivational interviewing. CARES is an acronym for the five qualities that help a diabetes care professional address DD effectively. These include confident competence, authentic accessibility, reciprocal respect, expressive empathy, and straight forward simplicity. WATER represents an easy to remember framework which helps facilitate successful conversation between patient and physician. It suggests five steps to be followed in every clinical encounter: welcome warmly, ask and assess; explain with empathy; and reassure and ensure return for the next consultation. These and other relevant tools, are included in [Table 11].{Table 11}

Patients and family should also be empowered to address DD, by offering diabetes education and coping skills training, as required. Coping skills training can be taught by various methods. We have found the AEIOU system[15] useful in the clinic. This mnemonic suggests practicing the following actions in hierarchal or step-wise order: Assess and Analyze coping mechanisms, Eliminate of the negative coping strategies, Introduce and Internalize the positive coping skills, Observe the changes regularly, and Upgrade one’s understanding continuously. Diabetes education should extend to the immediate family, colleagues at work, and other care givers too. The school teacher and bus driver of a child with diabetes, for example, should be trained in hypoglycemia prevention, identification, and management.

All stakeholders within the health-care system should be sensitized to the existence of DD, and its impact on diabetes care. Creating diabetes friendly atmosphere within health-care facilities, and outside of them, may help alleviate DD. DD can also be minimized if responsible patient centred care (RPCC) is followed in letter and spirit.[16]


DD is an undesired, but real and likely part of life with diabetes. An in-depth understanding of the etiopathogeneis, clinical features, and diagnostic tests of this condition can help diabetes care professionals approach affected persons and care givers in a sensitive and empathic manner. Such a strategy will facilitate prevention, early identification and management of DD, and thus achieve optimal health outcomes.


1American Diabetes Association. Standards of medical care in diabetes-2017. Diabetes Care 2017;40 Suppl 1:S39-40.
2Kreider KE. Diabetes distress or major depressive disorder? A practical approach to diagnosing and treating psychological comorbidities of diabetes. Diabetes Ther 2017;8:1-7.
3Gonzalez JS, Fisher L, Polonsky WH. Depression in diabetes: Have we been missing something important? Diabetes Care 2011;34:236-9.
4Fisher L, Hessler DM, Polonsky WH, Mullan J. When is diabetes distress clinically meaningful? establishing cut points for the Diabetes Distress Scale. Diabetes Care 2012;35:259-64.
5Diabetes Distress: A Real and Normal Part of Diabetes. Available from: [Last accessed on 2017 Mar 04].
6Fisher L, Mullan JT, Arean P, Glasgow RE, Hessler D, Masharani U. Diabetes distress but not clinical depression or depressive symptoms is associated with glycemic control in both cross-sectional and longitudinal analyses. Diabetes Care 2010;33:23-8.
7Polonsky WH, Fisher L, Earles J, Dudl RJ, Lees J, Mullan J, et al. Assessing psychosocial distress in diabetes: Development of the Diabetes Distress Scale. Diabetes Care 2005;28:626-31.
8Fisher L, Skaff MM, Mullan JT, Arean P, Mohr D, Masharani U, et al. Clinical depression versus distress among patients with type 2 diabetes: Not just a question of semantics. Diabetes Care 2007;30:542-8.
9Hermanns N, Caputo S, Dzida G, Khunti K, Meneghini LF, Snoek F. Screening, evaluation and management of depression in people with diabetes in primary care. Prim Care Diabetes 2013;7:1-10.
10Kalra S, Baruah MP, Das AK. Diabetes therapy by the ear: A bi-directional process. Indian J Endocrinol Metab 2015;19 Suppl 1:S4-5.
11Kalra S, Kumar S, Kalra B, Unnikrishnan A, Agrawal N, Sahay R. Patient-provider interaction in diabetes: Minimizing the discomfort of change. Internet J Fam Pract 2010;8:1.
12Kalra S, Gupta Y. Social pharmacology and diabetes. Indian J Pharmacol 2014;46:564.
13Kalra S, Kalra B. A good diabetes counselor ‘Cares’: Soft skills in diabetes counseling. Internet J Health 2010;11:1-3.
14Kalra S, Kalra B, Sharma A, Sirka M. Motivational interviewing: The water approach. Endocr J 2010;57:S391.
15Kalra S, Kalra B, Sharma A, Sirka M. Coping skills training: The AEIOU approach. Endocr J 2010;57:S391.
16Kalra S, Baruah MP, Unnikrishnan AG. Responsible patient-centered care. Indian Journal of Endocrinology and Metabolism. 2017 May;21(3):365.