This paper views caregiver stress as a consequence of a process comprising a number of interrelated conditions, including the socioeconomic characteristics and resources of caregivers and the primary and secondary stressors to which they are exposed. Primary stressors are hardships and problems anchored directly in caregiving. Secondary stressors fall into two categories: the strains experienced in roles and activities outside of caregiving, and intrapsychic strains, involving the diminishment of self-concepts. Coping and social support can potentially intervene at multiple points along the stress process.

OBJECTIVE -We sought to determine differences between structured interviews, symptom questionnaires, and distress measures for assessment of depression in patients with diabetes.RESEARCH DESIGN AND METHODS -We assessed 506 diabetic patients for major depressive disorder (MDD) by a structured interview (Composite International Diagnostic Interview [CIDI]), a questionnaire for depressive symptoms (Center for Epidemiological Studies Depression Scale [CESD]), and on the Diabetes Distress Scale. Demographic characteristics, two biological variables (A1C and non-HDL cholesterol), and four behavioral management measures (kilocalories, calories of saturated fat, number of fruit and vegetable servings, and minutes of physical activity) were assessed. Comparisons were made between those with and without depression on the CIDI and the CESD.RESULTS -Findings showed that 22% of patients reached CESD Ն16, and 9.9% met a CIDI diagnosis of MDD. Of those above CESD cut points, 70% were not clinically depressed, and 34% of those who were clinically depressed did not reach CESD scores Ն16. Those scoring Ն16, compared with those Ͻ16 on the CESD, had higher A1C, kilocalories, and calories of saturated fat and lower physical activity. No differences were found using the CIDI. Diabetes distress was minimally related to MDD but substantively linked to CESD scores and to outcomes.CONCLUSIONS -Most patients with diabetes and high levels of depressive symptoms are not clinically depressed. The CESD may be more reflective of general emotional and diabetesspecific distress than clinical depression. Most treatment of distress, however, is based on the depression literature, which suggests the need to consider different interventions for distressed but not clinically depressed diabetic patients. Diabetes Care 30:542-548, 2007P atients with diabetes and comorbid depressive symptoms, compared with patients with diabetes alone, have increased functional impairment, more hospital days and days off of work (1,2), poorer glycemic control (3), poorer self-management behavior (4), increased health care use and costs (5), and a higher risk of morbidity and mortality (6,7). Clearly, the co-occurrence of diabetes and depression has significant implications for clinical outcomes, disease management, health care costs, and patient health and well-being.The way depression is measured in clinical studies of diabetes, however, takes a number of different forms, and it is not at all clear whether each method similarly assesses depression and whether different methods uniformly classify patients. We may be identifying very different groups of patients by each method.The gold standard for assessment of clinical depression is a standardized, structured patient interview that yields clinical diagnoses that conform with Diagnostic and Statistical Manual of Psychiatric Disorders, 4th edition (DSM-IV) criteria. The most frequently used interview schedules are the Structured Clinical Interview for DSM (8), the Composite International Diagnostic Interview (CIDI) (9), ...

Aims-To report the prevalence and correlates of affective and anxiety disorders, depressive affect and diabetes distress over time.Methods-In a non-interventional study, 506 patients with Type 2 diabetes were assessed three times over 18 months (9-month intervals) for: major depressive disorder (MDD), general anxiety disorder (GAD), panic disorder (PANIC), dysthymia (DYS) (Composite International Diagnostic Interview); depressive affect [Center for Epidemiological Studies-Depression (CES-D)]; Diabetes Distress Scale (DDS); HbA 1c ; and demographic data.Results-Diabetic patients displayed high rates of affective and anxiety disorders over time, relative to community adults: 60% higher for MDD, 123% for GAD, 85% for PANIC, 7% for DYS. The prevalence of depressive affect and distress was 60-737% higher than of affective and anxiety disorders. The prevalence of individual patients with an affective and anxiety disorder over 18 months was double the rate assessed at any single wave. The increase for CES-D and DDS was about 60%. Persistence of CES-D and DDS disorders over time was significantly greater than persistence of affective and anxiety disorders, which tended to be episodic. Younger age, female gender and high comorbidities were related to persistence of all conditions over time. HbA 1c was positively related to CES-D and DDS, but not to affective and anxiety disorders over time.Conclusions-The high prevalence of comorbid disorders and the persistence of depressive affect and diabetes distress over time highlight the need for both repeated mental health and diabetes distress screening at each patient contact, not just periodically, particularly for younger adults, women and those with complications/comorbidities.

PURPOSE Previous research has documented that diabetes distress, defi ned 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. METHODSWe 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 (HbA 1c ); 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 highfrom 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 specifi city 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 HbA 1c , non-HDL cholesterol, and kilocalories consumed per day; none discriminated subgroups on fruit and vegetable servings consumed per day; and only the DDS3 yielded signifi cant 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 respondents to rate on a 6-point scale the degree to which the following items caused distress: (1) feeling overwhelmed by the demands of living with diabetes, and (2) feeling that I am often failing with my diabetes regimen. The DDS17 can be administered to those who have positive fi ndings on the DDS2 to defi ne the content of distress and to direct intervention.

Research both into the stress process and into the life course is concerned with changing lives. Yet, the conceptual paradigms that guide the work of these two fields are largely segregated, borrowing little from each other. This article explores some of the junctures at which the study of social stress might benefit from life-course perspectives and, conversely, those at which life-course research might profitably employ the vantage points of stress research. In the first case, an awareness of life-course trajectories can sensitize stress researchers to the restructuring of lives across time, particularly to the shifting landscape of stressors to which people are exposed and changes in their access to resources in dealing with the stressors. For its part, stress research may be useful in clarifying some basic life-course constructs. Thus, it can direct attention to conditions that help to define the experiential distinctiveness of historical cohorts and to conditions that produce intracohort variations. It is also useful in providing an interpretive framework for understanding how the timing and sequencing of transitional events impact people's lives. The perspectives of the stress process, finally, are also relevant to the critical appraisal of the constructs of life satisfaction and successful aging.