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To what extent is the elevated risk of psychological distress in people with diabetes accounted for by physical disability? Findings from a large population-based study
  1. Elza Elmira1,
  2. Emily Banks2,
  3. Grace Joshy1
  1. 1 National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
  2. 2 The Sax Institute, The Sax Institute, Sydney, New South Wales, Australia
  1. Correspondence to Dr Grace Joshy; grace.joshy{at}


Objectives People with diabetes experience an elevated risk of psychological distress compared with people without diabetes. It is unclear how much of this elevated risk is attributable to the greater levels of physical disability in people with diabetes, and how this risk varies according to sociodemographic and health-behavioural characteristics. This study quantified levels of psychological distress in people with and without diabetes, considering these factors.

Design Cross-sectional analysis of questionnaire data.

Setting Men and women aged ≥45 years, in the 45 and Up Study, from New South Wales, Australia.

Participants 236 441 people who completed the baseline postal questionnaire (distributed from 1 January 2006–31 December 2008), with valid data for diabetes status and psychological distress.

Primary outcome measures High psychological distress (Kessler-10 >22). Modified Poisson regression with robust error variance was used to estimate prevalence ratios (PRs), comparing prevalence of high psychological distress among those with and without diabetes and across physical functional limitation (PFL) levels, adjusting for potential confounders.

Results Overall, 8.4% (19 803/236 441) of participants reported diabetes. 11.8% (2339) of individuals with diabetes and 7.2% (15 664) without diabetes had high psychological distress: age-adjusted and sex-adjusted PR=1.89 (95% CI 1.81 to 1.97), becoming 1.58 (1.52 to 1.65) and 1.22 (1.17 to 1.27) following additional adjustment for sociodemographic factors, health behaviours and additionally for PFL, respectively. Compared with individuals with neither diabetes nor PFL, the adjusted PRs for high psychological distress were: 1.37 (1.17 to 1.60) with diabetes but no PFL, 7.33 (7.00 to 7.67) without diabetes but with severe PFL and 8.89 (8.36 to 9.46) with both diabetes and severe PFL.

Conclusions People with diabetes have a 60% greater risk of high psychological distress than people without diabetes; a substantial proportion of this elevation is attributable to higher levels of disability with diabetes, especially factoring in measurement error. Psychological distress is strongly related to physical impairment.

  • general diabetes
  • psychological distress
  • physical functioning limitation
  • physical disability
  • population based survey
  • diabetes

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  • Contributors GJ and EB designed the study. EE conducted the analyses and drafted the manuscript. GJ provided statistical and methodological support. All authors interpreted the data, and critically revised and approved the final manuscript.

  • Funding This specific project was supported by a Cardiovascular Disease Network Development Grant from the National Heart Foundation of Australia and a National Health and Medical Research Council of Australia Partnership Grant (GNT1092674). EB is supported by the National Health and Medical Research Council of Australia (1042717).

  • Competing interests None declared.

  • Patient consent Participants provided written consent to take part in the 45 and Up Study

  • Ethics approval The conduct of the 45 and Up Study was approved by the University of New South Wales Human Research Ethics Committee (HREC). Ethics approval for this study was obtained from the Australian National University Human Ethics Committee (2010/513) and the NSW Population and Health Services Research Ethics Committee (HREC/10/CIPHS/33; CI NSW Study Reference 2010/05/234).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Information about data access and governance policies is available at

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