Introduction
The Diabetes Distress Scale (DDS), developed by William H. Polonsky and colleagues in 2005, is a pivotal tool for assessing diabetes-specific emotional distress. With over 1,900 citations on Google Scholar, it has become a cornerstone in diabetes research and clinical practice. Specifically, the DDS identifies emotional, physician-related, regimen-related, and interpersonal distress, offering actionable insights for improving patient outcomes.
This article explores the DDS’s structure, validation, and applications, providing researchers and clinicians with a robust resource for diabetes management.
Key Features of the Diabetes Distress Scale (DDS)
Purpose and Use
The Behavioral Diabetes Institute published the DDS, which actively evaluates diabetes-specific emotional distress by focusing on challenges like disease management, social support, emotional burden, and healthcare access. Clinicians actively use it to screen for psychosocial issues, track distress over time, and shape treatment plans. Similarly, researchers depend on it for clinical trials and epidemiological studies, especially in type 1 and type 2 diabetes populations. For instance, high distress scores often link to poor glycemic control, so the DDS proves crucial for targeted interventions.
Target Population
The DDS is validated for adults aged 18 and older, including:
- Young Adults (18–24 years)
- Middle-Aged Adults (25–44 years)
- Older Adults (45–64 years)
- Seniors (65+ years)
It targets individuals with type 1 or type 2 diabetes without severe visual or cognitive impairments. Thus, it suits both clinical settings and research studies, though it is not validated for pediatric populations.
Structure of the Diabetes Distress Scale (DDS)
The DDS comprises 17 items within the domain of Endocrinology/Diabetes, covering four validated sub-domains:
- Emotional Burden (5 items: 1, 3, 8, 11, 14): Fear, anger, or feeling overwhelmed by diabetes (e.g., “Feeling that diabetes controls my life”).
- Physician-Related Distress (4 items: 2, 4, 9, 15): Concerns about healthcare access or provider support (e.g., “Feeling that my doctor doesn’t take my concerns seriously enough”).
- Regimen-Related Distress (5 items: 5, 6, 10, 12, 16): Challenges with medication or diet adherence (e.g., “Not feeling confident in my day-to-day ability to manage diabetes”).
- Interpersonal Distress (3 items: 7, 13, 17): Lack of social or family support (e.g., “Feeling that friends or family are not supportive enough of self-care efforts”).
Items of the Diabetes Distress Scale (DDS)
- Item 1: Feeling that diabetes is taking up too much of my mental and physical energy every day.
- Item 2: Feeling that my doctor doesn’t know enough about diabetes and diabetes care.
- Item 3: Feeling angry, scared, and/or depressed when I think about living with diabetes.
- Item 4: Feeling that my doctor doesn’t give me clear enough directions on how to manage my diabetes.
- Item 5: Feeling that I am not testing my blood sugars frequently enough.
- Item 6: Feeling that I am often failing with my diabetes routine.
- Item 7: Feeling that friends or family are not supportive enough of self-care efforts (e.g. planning activities that conflict with my schedule, encouraging me to eat the “wrong” foods).
- Item 8: Feeling that diabetes controls my life.
- Item 9: Feeling that my doctor doesn’t take my concerns seriously enough.
- Item 10: Not feeling confident in my day-to-day ability to manage diabetes.
- Item 11: Feeling that I will end up with serious long-term complications, no matter what I do.
- Item 12: Feeling that I am not sticking closely enough to a good meal plan.
- Item 13: Feeling that friends or family don’t appreciate how difficult living with diabetes can be.
- Item 14: Feeling overwhelmed by the demands of living with diabetes.
- Item 15: Feeling that I don’t have a doctor who I can see regularly enough about my diabetes.
- Item 16: Not feeling motivated to keep up my diabetes self management.
- Item 17: Feeling that friends or family don’t give me the emotional support that I would like.
Each item uses a 6-point Likert scale (1 = “Not a problem” to 6 = “Very serious problem”), assessing distress over the past month. As a result, it captures nuanced stressors efficiently.
Scoring Method of the Diabetes Distress Scale (DDS)
The DDS uses a clear scoring approach. Specifically, clinicians and researchers calculate a mean item score for each subscale and the overall questionnaire by summing the relevant item scores and dividing by the number of items:
- Total DDS Score: Sum all 17 item scores and divide by 17.
- Sub-Domain Scores:
- Emotional Burden: Sum items 1, 3, 8, 11, 14; divide by 5.
- Physician-Related Distress: Sum items 2, 4, 9, 15; divide by 4.
- Regimen-Related Distress: Sum items 5, 6, 10, 12, 16; divide by 5.
- Interpersonal Distress: Sum items 7, 13, 17; divide by 3.
Interpretation of the DDS Total and Sub Scale Scores:
- <2.0: Little or no distress.
- 2.0–2.9: Moderate distress.
- ≥3.0: High distress, indicating clinical concern and potential poor glycemic control and self-care.
Thus, this scoring system empowers clinicians to prioritize interventions and researchers to analyze distress trends effectively.
Administration Format
The questionnaire can be administered in multiple formats, including:
- paper-based forms.
- interviews (in-person, phone, or video call).
- digital platforms.
The questionnaire is self-administered and generally takes 10–15 minutes to complete, making it highly practical for busy clinical and research environments.
Applications of the Diabetes Distress Scale (DDS)
The DDS serves multiple purposes:
- Screening: Identifies patients with significant diabetes-related distress, signaling the need for psychosocial support.
- Monitoring: Tracks changes in distress over time, particularly during interventions.
- Research: Supports clinical trials and studies evaluating diabetes management strategies.
For example, a clinician might use a score ≥3.0 to recommend counseling, while researchers examine distress patterns to enhance self-management programs. Moreover, its ability to distinguish diabetes-specific distress from general depression boosts its clinical precision.
Languages and Availability
To ensure global accessibility, the DDS is available in multiple languages, including:
- Arabic
- English
- Spanish
- French
- German
- Japanese
Additionally, it includes Mandarin Chinese, Portuguese, and over 20 other languages, thus broadening its utility across diverse populations. The Behavioral Diabetes Institute manages the DDS under a proprietary license, offering it free for non-commercial use. For inquiries, contact William H. Polonsky at whpolonsky@aol.com.
Reliability and Validity
The DDS demonstrates high reliability and validity, with a Cronbach’s alpha of 0.93 for the total scale and subscale alphas for the four subscales:
- Emotional Burden: 0,88
- Physician-Related Distress: 0.88
- Regimen-Related Distress: 0.90
- Interpersonal Distress: 0.88
Moreover, test-retest reliability shows intraclass correlation coefficients (ICC) of 0.78–0.946. Its convergent validity is supported by correlations with HbA1c (r = 0.16–0.21) and DDS total scores were positively associated with depressive symptomatology (CESD; r = 0.56). Consequently, its robust psychometric properties make it a trusted tool for both clinical and research applications.
Validation studies include:
Limitations and Considerations
Despite its strengths, the DDS has a few limitations:
- Self-Report measure: Respondents may be influenced by social desirability bias or personal interpretation.
- Cultural Bias: Some translations may lack full validation, potentially affecting accuracy in certain populations.
- Lack of Sensitivity to Change: It may not fully capture subtle changes in distress over short periods.
- Age Restrictions: Not validated for individuals under 18, limiting its pediatric use.
- Social desirability bias: Patients might alter their responses to present themselves in a more favorable light.
Other Versions and Related Questionnaires
In addition to the full DDS, other versions and related instruments are available to suit various clinical and research needs:
- DDS-2: A brief, 2-item screener that can be used for a quick assessment.
- Parent/Partner DDS: An adaptation designed for caregivers.
Furthermore, researchers and clinicians may find it beneficial to use the DDS alongside other complementary questionnaires, such as the Problem Areas in Diabetes (PAID), Diabetes Empowerment Scale (DES) and the T2-DDAS (newer distress assessment) to obtain a more comprehensive view of a patient’s psychosocial state.
Additional Resources
For further exploration, consider these resources:
- Access the Original Validation Study.
- Validation studies for different languages include: Bangladeshi, Arabic, Hindi, Moroccan, Russian and Japanese.
- Access the online DDS-17 Questionnaire here: DDS-17 English Version.
- For inquiries, contact William H. Polonsky at whpolonsky@aol.com.
- For additional resources, consult the Behavioral Diabetes Institute.
Frequently Asked Questions (FAQ)
- Who can use the DDS?
Clinicians, researchers, and healthcare providers use the DDS for adults aged 18 and older with type 1 or type 2 diabetes. - How long does it take to complete the DDS?
Patients typically take 10–15 minutes to complete the DDS, making it feasible for clinical and research settings. - How is the DDS administered?
Healthcare teams can administer it via paper-based, digital, interview, or phone/video call formats, offering flexibility. - Is there any cost to using the DDS?
The DDS is free for non-commercial use, and it holds a proprietary license managed by the Behavioral Diabetes Institute.
A word from ResRef about the Diabetes Distress Scale (DDS)
The DDS transforms diabetes care by actively revealing hidden emotional burdens that hinder self-management, thereby making it essential for holistic, patient-centered approaches.
References
- Polonsky WH, Fisher L, Earles J, Dudl RJ, Lees J, Mullan J, Jackson RA. Assessing psychosocial distress in diabetes: development of the diabetes distress scale. Diabetes Care. 2005 Mar;28(3):626-31. doi: 10.2337/diacare.28.3.626. PMID: 15735199. Study link.
- Akter J, Islam RM, Chowdhury HA, Selim S, Biswas A, Mozumder TA, Broder J, Ilic D, Karim MN. Psychometric validation of diabetes distress scale in Bangladeshi population. Sci Rep. 2022 Jan 12;12(1):562. doi: 10.1038/s41598-021-04671-0. PMID: 35022493; PMCID: PMC8755848. Study link.
- Batais MA, Alosaimi FD, AlYahya AA, Aloofi OA, Almashouq MK, Alshehri KS, Alfraiji AF. Translation, cultural adaptation, and evaluation of the psychometric properties of an Arabic diabetes distress scale: A cross sectional study from Saudi Arabia. Saudi Med J. 2021 May;42(5):509-516. doi: 10.15537/smj.2021.42.5.20200286. PMID: 33896780; PMCID: PMC9149698. Study link.
- , A., Khapre, M., Kant, R. et al.Diabetes-related distress: translation and validation of the Hindi version of Diabetes Distress Scale (DDS) for Indian type 2 diabetes mellitus patients. Int J Diabetes Dev Ctries 45, 141–149 (2025). Study link.
- Likhodey N.V., Epishin V.E., Kalashnikova M.F., Kaurova A.M., Tulupova M.V., Sych Y.P., Bondareva I.B. Adaptation of The Diabetes Distress Scale on a Russian-speaking sample of patients with type 1 and type 2 diabetes mellitus. Diabetes mellitus. 2024;27(5):429-440. (In Russ.) Study link.
- NENE TAKAMI, KENTARO OKAZAKI, NORIYUKI TAKAHASHI, MINA SUEMATSU, WATARU OHASHI; 810-P: Japanese Version of the Diabetes Distress Scale: Validation and Identification of Individuals at High Risk for Diabetes-Related Distress. Diabetes1 June 2019; 68 (Supplement_1): 810–P. Study link.
- Fisher L, Glasgow RE, Mullan JT, Skaff MM, Polonsky WH. Development of a brief diabetes distress screening instrument. Ann Fam Med. 2008 May-Jun;6(3):246-52. doi: 10.1370/afm.842. PMID: 18474888; PMCID: PMC2384991. Study link.
