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Diabetes Distress Scale Scoring

Screening For Emotional Problems In Adolescents

Screening For Emotional Problems In Adolescents

Adolescence (12-20 years) is a psychologically vulnerable period that is particularly challenging in the face of type 1 diabetes. Contributing challenges include the need to experience and seek autonomy (with associated risk taking behaviours), not wanting to be different from peers and the impact of hormonal changes (puberty) that can seriously disrupt glycaemic control and induce frustration. Clinically relevant depressive symptoms are elevated in adolescents with type 1 diabetes and estimated to present in 15-25% of the young patients [1][2][3]. These symptoms are burdensome in itself and associated with poor adherence, suboptimal glycaemic control, and recurrent diabetic ketoacidosis. Other emotional problems (anxiety, anger, distress) appear also highly prevalent, so in addition to increased risk for depressive symptoms, adolescents with type 1 diabetes are at increased risk for poor coping and problem-solving skills, poor self-care [4]and negative diabetes-specific health outcomes such as suboptimal glycaemic control and recurrent diabetic ketoacidosis [5]. There are gender differences, with adolescent girls reporting higher levels of depressive symptoms than boys across all ethnic groups [6]. There are also indications that disturbed eating behaviours are more prevalent in girls with type 1 diabetes compared to healthy controls [7]. Periodic monitoring of adolescents’ Quality of Life (QoL) is recommended for all patients using well validated and reliable measures such as the multidimensional MY-Q [8]. This enables detection and discussion of psychosocial issues, including low mood in the context of diabetes management. When psychosocial problems are identified, screening for depression is advised as a second step (case-finding). For known high-risk patients (e, Continue reading >>

The Importance Of Screening For Mild Depression In Adults With Diabetes

The Importance Of Screening For Mild Depression In Adults With Diabetes

1School of Psychiatry, Faculty of Medicine and Black Dog Institute, University of New South Wales, Randwick, NSW, Australia 2St VincentâÂÂs Urban Mental Health Research Institute, St VincentâÂÂs Hospital, Sydney, NSW, Australia 3Consultation Liaison Psychiatry, St VincentâÂÂs Hospital, Sydney, NSW, Australia 4Diabetes Services, St VincentâÂÂs Hospital, Sydney, NSW, Australia 5School of Medicine, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia 6Department of Psychological and Addiction Medicine, Australian National University, Canberra ACT, Australia *Corresponding Author: Kay Wilhelm St VincentâÂÂs Urban Mental Health Research Institute St VincentâÂÂs Hospital, Sydney, NSW, Australia Tel: +61416143717 Fax: +61(02)83821402 E-mail: [email protected] Citation: Wilhelm K, Reddy J, Crawford J, et al. The Importance of Screening for Mild Depression in Adults with Diabetes. Transl Biomed. 2017, 8:1. doi:10.2167/2172-0479.1000101 Abstract Aim: While the impact of major depression on diabetes has gained increasing attention, the role of minor depression is less well investigated. This observational study compared three groups of adults with Type 1 (T1DM) or Type 2 (T2DM) diabetes mellitus: with me) no depressive symptoms (NODEP), ii) mild depressive symptoms (MILD) and iii) moderate-to-severe symptoms (MOD/SEVERE)-on diabetes distress, psychological distress, anxiety and somatic symptoms, quality of life and HbA1c levels. Methods: 245 outpatients attending two hospital diabetes services (27% with T1DM; 73% with T2DM) completed self-report measures including patient health questionnaire (PHQ), problem areas in diabetes (PAID) scale and short form health survey (SF12). Participants were interviewed by a psychiatrist Continue reading >>

Understanding The Areas And Correlates Of Diabetes-related Distress In Parents Of Teens With Type 1 Diabetes

Understanding The Areas And Correlates Of Diabetes-related Distress In Parents Of Teens With Type 1 Diabetes

Objective To identify the unique areas of diabetes-related distress (DD) for parents of teens with type 1 diabetes and parent and teen characteristics associated with DD. Methods Areas of DD were developed from structured interviews and translated into 46 survey items. Items were analyzed with exploratory factor analysis (EFA). Results An EFA with 332 parents (88% mothers) reduced items to four Parent Diabetes Distress Scale (PDDS) factors (20 items, α = .94): Personal, Teen Management, Parent/Teen Relationship, and Healthcare Team Distress. Parent DD was higher among fathers, younger or single parents, parents of teens with higher hemoglobin A1c or severe low blood glucose levels, authoritarian parenting, depressive symptoms, and low emotional support. Conclusions 4 areas of parent DD were identified using a newly developed measure, the PDDS. DD was associated with family demographic, teen diabetes status, and parent contextual factors, and can help identify parents who may be more vulnerable to DD. Raising a teen with type 1 diabetes (T1D) can be challenging and stressful. As the disagreements over independence and responsibilities grow over the teen years, parents experience many burdens and worries, including conflicts with their teens about T1D self-management and concerns about their teens’ safety (especially in regards to low blood glucose levels; Streisand, Swift, Wickmark, Chen, & Holmes, 2005 ). A recent review found that approximately one-third of parents reported severe emotional distress at the time their child was diagnosed, and 20% reported high levels of emotional distress 1–4 years after diagnosis ( Whittemore, Jaser, Chao, Jang, & Grey, 2012 ). A number of studies have shown significant relationships between elevated parental emotional distress wi Continue reading >>

Development Of A Brief Diabetes Distress Screening Instrument

Development Of A Brief Diabetes Distress Screening Instrument

Go to: Abstract 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 (HbA1c); 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 ≥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 HbA1c, 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 respo Continue reading >>

Diabetes Distress Scale-17 Implementation Among Patients With Diabetes: Turkish Validity And Reliability Study

Diabetes Distress Scale-17 Implementation Among Patients With Diabetes: Turkish Validity And Reliability Study

June, 2016 >> Goksen Erkin, Haluk Mergen, Tevfik Tanju Yilmazer ( Department of Family Medicine, Izmir Tepecik Training & Research Hospital, Turkey. ) Kurtulus Ongel ( Faculty of Medicine, Department of Family Medicine, Izmir Katip Celebi University, Turkey. ) Berna Erdogmus Mergen ( Department of Family Medicine, Izmir Karabaglar Community Health Center, Izmir, Turkey. ) Read PDF Abstract Objective: To prove reliability and validity of the Turkish version of diabetes distress scale. Methods: The cross-sectional study was conducted at Tepecik Training and Research Hospital, Izmir, Turkey, from July 2011 to February 2012, and comprised diabetics whose ages ranged from 25 to 86 years who voluntarily participated in the study. Descriptive statistics, exploratory and confirmatory factor analyses were used for reliability and validity evaluations. SPSS 21 was used for data analysis. Results: Of the 165 patients, 87(52.7%) were women and 78(47.3%) were men. Overall, 32(19.4%) patients had normal weight, 52(31.5%) were overweight, 74(44.8%) were obese and 7(4.2%) were morbid obese. Mean age was 53.69±11.39 years. Mean score was 50.87±11.53 points (range: 23 to 84). As for distress distribution, 15(9.1%) patients had no problem (0-34 points), 141(85.5%) moderate (35-68 points) and 9(5.5%) had high (>68 points).Fasting blood glucose was higher than 200 mg/dl in 22(13.2%) patients. Conclusion: Turkish diabetes distress scale-17 was found to be valid and reliable and had satisfying fit-index parameters. Keywords: Diabetes, Distress, Validity, Reliability. (JPMA 66: 662; 2016) Introduction Diabetes Mellitus (DM) is a metabolic and endocrinologic disease originating from lack of insulin and/or impairment of effect or both.1 It is a metabolic disorder with chronic progress,2,3 and Continue reading >>

Diabetes Distress In Adults With Type 1 Diabetes: Prevalence, Incidence And Change Over Time

Diabetes Distress In Adults With Type 1 Diabetes: Prevalence, Incidence And Change Over Time

Go to: 1.0 INTRODUCTION Diabetes distress (DD) refers to the emotional distress associated with the ongoing worries, burdens and concerns that occur when managing a demanding chronic disease like diabetes over time [1]. Although often confused with depression, unlike depression DD is directly linked with poor glycemic control and problematic self-care behaviors [2–6]. Recent studies have indicated that among type 2 adults (T2D) elevated DD is highly stable over time and that the point prevalence of elevated DD is approximately 46%, suggesting a widespread clinical problem in this population [7]. To date, however, no systematic analysis of the prevalence, incidence and stability of DD over time among adults with type 1 diabetes (T1D) has occurred. Given the importance of DD with respect to quality of life and disease management, one important but often neglected question is: How much change in DD among adults with T1D over time should be considered meaningful? For clinicians and individuals with T1D, this highlights the need to identify how much DD must decrease before an intervention might be considered successful or how much DD must increase before an intervention should be initiated; for clinical researchers, this issue is critical in order to demonstrate meaningful change in DD as a result of a new device or treatment [8]. Standardizing the cut-points and parameters of stability and change in DD over time also permits studies of correlates of DD and predictors of change so that individuals at risk can be identified. The goals of the present study were to identify criteria for elevated DD, clock patterns of stability and change over time and document how much change in DD among adults with T1D needs to occur to be meaningful. The Type 1 Diabetes Distress Scale (T1-D Continue reading >>

What Is The Best Measure For Assessing Diabetes Distress? A Comparison Of The Problem Areas In Diabetes And Diabetes Distress Scale: Results From Diabetes Miles–australia

What Is The Best Measure For Assessing Diabetes Distress? A Comparison Of The Problem Areas In Diabetes And Diabetes Distress Scale: Results From Diabetes Miles–australia

This study used Rasch analysis to examine the psychometric validity of the Diabetes Distress Scale and the Problem Areas in Diabetes scale to assess diabetes distress in 3338 adults with diabetes (1609 completed the Problem Areas in Diabetes scale (n = 675 type 1 diabetes; n = 934 type 2 diabetes) and 1705 completed the Diabetes Distress Scale (n = 693 type 1 diabetes; n = 1012 type 2 diabetes)). While criterion and convergent validity were good, Rasch analysis revealed suboptimal precision and targeting, and item misfit. Unresolvable multidimensionality within the Diabetes Distress Scale suggests a total score should be avoided, while suboptimal precision suggests that the Physician-related and Interpersonal distress subscales should be used cautiously. Bech, P (2004) Measuring the dimension of psychological general well-being by the WHO-5. Quality of Life Newsletter 32: 15–16. Google Scholar Bond, TG, Fox, CM (2001) Applying the Rasch Model: Fundamental Measurement in the Human Sciences. London: Lawrence Erlbaum Associates. Google Scholar Boone, W, Staver, J, Yale, M (2014) Rasch Analysis in the Human Sciences. Dordrecht: Springer. Google Scholar, Crossref Borsboom, D (2006) The attack of the psychometricians. Psychometrika 71: 425–440. Google Scholar, Crossref, Medline Cappelleri, JC, Jason Lundy, J, Hays, RD (2014) Overview of classical test theory and item response theory for the quantitative assessment of items in developing patient-reported outcomes measures. Clinical Therapeutics 36: 648–662. Google Scholar, Crossref, Medline Egede, LE, Zheng, D, Simpson, K (2002) Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes. Diabetes Care 25: 464–470. Google Scholar, Crossref, Medline Fisher, L, Glasgow, Continue reading >>

Psychometric Properties Of The Thai Version Of The Diabetes Distress Scale In Diabetic Seniors

Psychometric Properties Of The Thai Version Of The Diabetes Distress Scale In Diabetic Seniors

Kattika Thanakwang, Wantana Thinganjana, Roumporn Konggumnerd Institute of Nursing, Suranaree University of Technology, Nakhon Ratchasima, Thailand Background: The Diabetes Distress Scale (DDS) is an important measure of diabetes-related emotional distress that has been widely used in the Western world. In Thailand, there is a lack of reliable and valid scales for assessing distress levels in diabetes patients, specifically in older adults. Objectives: The main objectives of this study were to adapt the DDS for use in Thai diabetic elderly and to evaluate its psychometric properties. Methods: The 17-item DDS was linguistically adapted using forward–backward translation and administered to 170 diabetic patients ≥60 years selected from diabetes outpatient clinics of four hospitals in Buriram, Thailand. Statistical analyses included exploratory factor analysis, internal consistency, convergent validity, and test–retest reliability. Results: During factor analysis, a three-factor solution was found to be reasonable for the sub-dimensions of emotional and regimen-related burden (ten items), physician- and nurse-related distress (four items), and diabetes-related interpersonal distress (three items). The Cronbach’s alpha coefficient for the total score was 0.95 and varied between 0.85 and 0.96 in the three subscales. The results provided evidence that supports the convergent validity of the Thai version of the DDS as well as its stability. Conclusion: The Thai version of the DDS has acceptable psychometric properties. It enables assessment of diabetes-specific distress in elderly patients and has the advantage of being easy to use in both clinical and research settings. Keywords: diabetes distress scale, psychometric properties, diabetes-related stress, diabetic elder Continue reading >>

Assessing Psychosocial Distress In Diabetes

Assessing Psychosocial Distress In Diabetes

Development of the Diabetes Distress Scale Abstract OBJECTIVE—The purpose of this study was to describe the development of the Diabetes Distress Scale (DDS), a new instrument for the assessment of diabetes-related emotional distress, based on four independent patient samples. RESEARCH DESIGN AND METHODS—In consultation with patients and professionals from multiple disciplines, a preliminary scale of 28 items was developed, based a priori on four distress-related domains: emotional burden subscale, physician-related distress subscale, regimen-related distress subscale, and diabetes-related interpersonal distress. The new instrument was included in a larger battery of questionnaires used in diabetes studies at four diverse sites: waiting room at a primary care clinic (n = 200), waiting room at a diabetes specialty clinic (n = 179), a diabetes management study program (n = 167), and an ongoing diabetes management program (n = 158). RESULTS—Exploratory factor analyses revealed four factors consistent across sites (involving 17 of the 28 items) that matched the critical content domains identified earlier. The correlation between the 28-item and 17-item scales was very high (r = 0.99). The mean correlation between the 17-item total score (DDS) and the four subscales was high (r = 0.82), but the pattern of interscale correlations suggested that the subscales, although not totally independent, tapped into relatively different areas of diabetes-related distress. Internal reliability of the DDS and the four subscales was adequate (α > 0.87), and validity coefficients yielded significant linkages with the Center for Epidemiological Studies Depression Scale, meal planning, exercise, and total cholesterol. Insulin users evidenced the highest mean DDS total scores, whereas die Continue reading >>

Relationships Of Diabetes-specific Emotional Distress, Depression, Anxiety, And Overall Well-being With Hba1c In Adult Persons With Type 1 Diabetes

Relationships Of Diabetes-specific Emotional Distress, Depression, Anxiety, And Overall Well-being With Hba1c In Adult Persons With Type 1 Diabetes

Highlights • Diabetes-specific distress was significantly related to glycemic control. • Regimen distress had the strongest association with glycemic control. • Well-being, depression, and anxiety were not significantly related to HbA1c. Abstract Emotional problems are common in adults with diabetes, and knowledge about how different indicators of emotional problems are related with glycemic control is required. The aim was to examine the relationships of diabetes-specific emotional distress, depression, anxiety, and overall well-being with glycosylated hemoglobin (HbA1c). Of the 319 adults with type 1 diabetes attending the endocrinology outpatient clinic at a university hospital in Norway, 235 (74%) completed the Diabetes Distress Scale, the Problem Areas in Diabetes Survey, the Hospital Anxiety and Depression Scale, and the World Health Organization-Five Well-Being Index. Blood samples were taken at the time of data collection to determine HbA1c. Regression analyses examined associations of diabetes-specific emotional distress, anxiety, depression, and overall well-being with HbA1c. The relationship between diabetes-specific emotional distress and HbA1c was tested for nonlinearity. Diabetes-specific emotional distress was related to glycemic control (DDS total: unstandardized coefficient = 0.038, P < .001; PAID total: coefficient = 0.021, P = .007), but depression, anxiety, and overall well-being were not. On the DDS, only regimen-related distress was independently related to HbA1c (coefficient = 0.056, P < .001). A difference of 0.5 standard deviation of baseline regimen distress is associated with a difference of 0.6 in HbA1c. No significant nonlinearity was detected in the relationship between diabetes-specific distress and HbA1c. To stimulate adequate care Continue reading >>

Short-form Measures Of Diabetes-related Emotional Distress: The Problem Areas In Diabetes Scale (paid)-5 And Paid-1

Short-form Measures Of Diabetes-related Emotional Distress: The Problem Areas In Diabetes Scale (paid)-5 And Paid-1

Abstract We wanted to identify a five-item short form of the Problem Areas in Diabetes Scale and a single-item measure for rapid screening of diabetes-related emotional distress. Using an existing database of 1,153 patients with diabetes, we conducted a principal-components analysis to identify a set of five items and then conducted a reliability analysis and validity checks. From those five items, we identified the item with the strongest psychometric properties as a one-item screening tool. We identified a reliable and valid short version of the Problem Areas in Diabetes Scale (PAID) comprising five of the emotional-distress questions of the full PAID items (PAID-5, with items 3, 6, 12, 16, 19). The PAID-5 has satisfactory sensitivity (94%) and specificity (89%) for recognition of diabetes-related emotional distress. We also identified a one-item screening tool, the PAID-1 (Question 12: Worrying about the future and the possibility of serious complications), which has concurrent sensitivity and specificity of about 80% for the recognition of diabetes-related emotional distress. The PAID-5 and PAID-1 appear to be psychometrically robust short-form measures of diabetes-related emotional distress. Measure Cronbach’s α (95% CI) Subsample 1 (n = 589) Subsample 2 (n = 564) PAID-5 0.86 (0.84–0.88) 0.83 (0.80–0.85) PAID-Treatment problems 0.67 (0.63–0.72) 0.66 (0.60–0.70) PAID-Food problems 0.77 (0.73–0.80) 0.78 (0.75–0.81) PAID-Lack of social support r = 0.54a r = 0.66a WHO-5 0.84 (0.82–0.86) 0.85 (0.83–0.87) Notes We are grateful to N. Zandbelt and W. Cleijne for their assistance in data management and to Novo Nordisk for an unrestricted research grant to conduct the DAWN MIND study. The DAWN MIND study is supported by an unrestricted research grant from Continue reading >>

When Is Diabetes Distress Clinically Meaningful?

When Is Diabetes Distress Clinically Meaningful?

Abstract OBJECTIVE To identify the pattern of relationships between the 17-item Diabetes Distress Scale (DDS17) and diabetes variables to establish scale cut points for high distress among patients with type 2 diabetes. RESEARCH DESIGN AND METHODS Recruited were 506 study 1 and 392 study 2 adults with type 2 diabetes from community medical groups. Multiple regression equations associated the DDS17, a 17-item scale that yields a mean-item score, with HbA1c, diabetes self-efficacy, diet, and physical activity. Associations also were undertaken for the two-item DDS (DDS2) screener. Analyses included control variables, linear, and quadratic (curvilinear) DDS terms. RESULTS Significant quadratic effects occurred between the DDS17 and each diabetes variable, with increases in distress associated with poorer outcomes: study 1 HbA1c (P < 0.02), self-efficacy (P < 0.001), diet (P < 0.001), physical activity (P < 0.04); study 2 HbA1c (P < 0.03), self-efficacy (P < 0.004), diet (P < 0.04), physical activity (P = NS). Substantive curvilinear associations with all four variables in both studies began at unexpectedly low levels of DDS17: the slope increased linearly between scores 1 and 2, was more muted between 2 and 3, and reached a maximum between 3 and 4. This suggested three patient subgroups: little or no distress, <2.0; moderate distress, 2.0–2.9; high distress, ≥3.0. Parallel findings occurred for the DDS2. CONCLUSIONS In two samples of type 2 diabetic patients we found a consistent pattern of curvilinear relationships between the DDS and HbA1c, diabetes self-efficacy, diet, and physical activity. The shape of these relationships suggests cut points for three patient groups: little or no, moderate, and high distress. RESEARCH DESIGN AND METHODS Subjects Baseline samples f Continue reading >>

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Get Unlimited Access On Medscape.

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Assessing Psychosocial Distress In Diabetes: Development Of The Diabetes Distress Scale

Assessing Psychosocial Distress In Diabetes: Development Of The Diabetes Distress Scale

The purpose of this study was to describe the development of the Diabetes Distress Scale (DDS), a new instrument for the assessment of diabetes-related emotional distress, based on four independent patient samples. In consultation with patients and professionals from multiple disciplines, a preliminary scale of 28 items was developed, based a priori on four distress-related domains: emotional burden subscale, physician-related distress subscale, regimen-related distress subscale, and diabetes-related interpersonal distress. The new instrument was included in a larger battery of questionnaires used in diabetes studies at four diverse sites: waiting room at a primary care clinic (n = 200), waiting room at a diabetes specialty clinic (n = 179), a diabetes management study program (n = 167), and an ongoing diabetes management program (n = 158). Exploratory factor analyses revealed four factors consistent across sites (involving 17 of the 28 items) that matched the critical content domains identified earlier. The correlation between the 28-item and 17-item scales was very high (r = 0.99). The mean correlation between the 17-item total score (DDS) and the four subscales was high (r = 0.82), but the pattern of interscale correlations suggested that the subscales, although not totally independent, tapped into relatively different areas of diabetes-related distress. Internal reliability of the DDS and the four subscales was adequate (alpha > 0.87), and validity coefficients yielded significant linkages with the Center for Epidemiological Studies Depression Scale, meal planning, exercise, and total cholesterol. Insulin users evidenced the highest mean DDS total scores, whereas diet-controlled subjects displayed the lowest scores (P < 0.001). The DDS has a consistent, generalizabl Continue reading >>

Ethnic Minorities With Diabetes Differ In Depressive And Anxiety Symptoms And Diabetes-distress

Ethnic Minorities With Diabetes Differ In Depressive And Anxiety Symptoms And Diabetes-distress

Copyright © 2017 Charlotte B. Schmidt et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. To determine the association between ethnicity, diabetes-distress, and depressive and anxiety symptoms in adult outpatients with diabetes. Research Design and Methods. Diabetes-distress (Problem Areas in Diabetes Scale, PAID5), depressive and anxiety symptoms (Extended Kessler-10, EK10), and quality of life (Short-Form 12, SF12) were assessed in an ethnic diverse diabetes outpatient population of a teaching hospital in Amsterdam. Descent of one’s parents and self-classified ethnicity were obtained to define ethnicity. HbA1c, clinical data, and socioeconomic status were derived from the medical charts. Based on established cut-offs for PAID5- and EK10-scores, emotional distress was dichotomized for the purpose of logistic regression analyses. Results. Of 1007 consecutive patients approached, 575 participated. Forty-nine percent were of non-Dutch ethnicity and 24.7% had type 1 diabetes. Diabetes-distress was reported by 12.5% of the native Dutch patients and by 22.0%, 34.5%, and 42.6% of the Surinamese, Turkish, and Moroccan patients, respectively. Prevalence of depressive symptoms was 9.4% in native Dutch patients and 20.4%, 34.5%, and 27.3% in the other groups mentioned. Diabetes-distress and Moroccan origin were significantly associated (OR = 3.60, ) as well as depressive symptoms and Turkish origin (OR = 4.23, ). Conclusions. Different ethnic minorities with diabetes vary in their vulnerability for emotional distress, warranting clinical attention. Future research should elucidate explanatory factor Continue reading >>

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