JOURNAL OF MEDICAL INTERNET RESEARCH Bassi et al

Review

Assessment of Psychological Distress in Adults With Type 2

Diabetes Mellitus Through Technologies: Literature Review

Giulia Bassi1*, PhD; Silvia Gabrielli2*, PhD; Valeria Donisi2*, PhD; Sara Carbone2*, MSc; Stefano Forti2*, PhD; Silvia
Salcuni1*, PhD
1
Department of Developmental Psychology and Socialization, University of Padova, Padova, Italy
2
Fondazione Bruno Kessler, Trento, Italy
*
all authors contributed equally

Corresponding Author:
Giulia Bassi, PhD
Department of Developmental Psychology and Socialization
University of Padova
Via Venezia 12
Padova, 35131
Italy
Phone: 39 393477334405
Email: giulia.bassi@phd.unipd.it

Abstract
Background: The use of technological devices can support the self-management of individuals with type 2 diabetes mellitus
(T2DM), particularly in addressing psychological distress. However, there is poor consistency in the literature regarding the use
of psychological instruments for the web-based screening of patients’ psychological distress and subsequent monitoring of their
psychological condition during digital interventions.
Objective: This study aims to review previous literature on the types of psychological instruments delivered in digital interventions
for assessing depression, anxiety, and stress in patients with T2DM.
Methods: The literature review was conducted using the PsycINFO, CINAHL and PubMed databases, in which the following
terms were considered: diabetes mellitus, measure, assessment, self-care, self-management, depression, anxiety, stress, technology,
eHealth, mobile health, mobile phone, device, and smartphone.
Results: In most studies, psychological assessments were administered on paper. A few studies deployed self-reporting techniques
employing automated telephonic assessment, a call system for screening and monitoring patients’ conditions and preferences, or
through telephone interviews via interactive voice response calls, a self-management support program leveraging tailored messages
and structured emails. Other studies used simple telephone interviews and included the use of apps for tablets and smartphones
to assess the psychological well-being of patients. Finally, some studies deployed mood rating scales delivered through tailored
text message–based support systems.
Conclusions: The deployment of appropriate psychological tools in digital interventions allows researchers and clinicians to
make the screening of anxiety, stress, and depression symptoms faster and easier in patients with T2DM. Data from this literature
review suggest that mobile health solutions may be preferred tools to use in such digital interventions.

(J Med Internet Res 2021;23(1):e17740) doi: 10.2196/17740

KEYWORDS
type 2 diabetes mellitus; technology assessment; psychological distress; technology; review; mobile phone

psychological habits. According to several studies, T2DM is

Introduction associated with significant psychological impairments,
Background particularly depression, anxiety, and stress [1-4]. The prevalence
of depression (22.4%) and anxiety (32%) in individuals with
After the diagnosis of type 2 diabetes mellitus (T2DM), people T2DM is considerably higher than that in the general population
have to follow new lifestyles by changing their physical and (10%), with a negative impact on the disease itself [5]. The

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prevalence of depressive symptoms in older adults with T2DM management, there are inconsistent findings regarding the type
can be as high as 79.4% [6]. Indeed, some studies have reported of technological devices through which the best psychological
that high levels of anxiety, depression, and stress tend to cause instruments, developed as paper-and-pencil tools, should be
impairment in health-related quality of life and poor disease delivered to achieve a more in-depth screening of patients’
outcomes [6-9]. Factors that affect the quality of life of patients psychological distress and thereby better outline the
with T2DM include medical comorbidities [10], older age [11], psychological intervention [22].
female gender [12], and living in rural areas [10]. For instance,
authors have suggested that poor glycemic control is associated
Objective
with the onset of depressive symptoms [7,8] as well as diabetes This paper intends to identify and outline the types of
distress [9], and these symptoms can improve with better technological devices through which psychological instruments
glycemic control. In particular, diabetes distress is different should be delivered for an accurate assessment of
from psychological distress, as the latter refers to a general state diabetes-related psychological symptoms, such as stress,
of emotional disturbance consisting of symptoms of depression depression, and anxiety, in which technology represents support
and anxiety [13], whereas diabetes distress or diabetes-specific aid for self-care and self-management of T2DM. Indeed, a
distress is a specific term that describes an emotional state where precise assessment of psychological symptoms through
individuals experience stress, guilt or denial, and the burden of technologies in the field of diabetes is crucial to identify and
self-management due to diabetes itself. If such symptoms remain understand problematic areas to better manage the disease itself,
untreated, mild diabetes distress can result in severe diabetes reduce such symptoms, and facilitate the management of the
distress and/or depression [14,15]. Moreover, individuals with disease itself. Although the number of psychological instruments
T2DM who have reported symptoms of anxiety should be designed specifically for diabetes has increased, reviews of
motivated to self-monitor glycemic levels while they are psychological instruments integrated into technological devices
symptomatic [6]. Indeed, symptoms of anxiety during for assessing psychological symptoms are generally scarce
euglycemia—a normal level of sugar in the blood—would be among patients with T2DM. More specifically, the aim of this
suggestive of an anxiety disorder [6]. People with T2DM also review is two-fold: (1) to summarize the types of technological
presented with more stress symptoms compared with individuals devices used to administer self-report questionnaires for the
who do not have this chronic disease [16]. Several studies have assessment of psychological symptoms among individuals with
highlighted that stress symptoms can interact with the endocrine T2DM, with a specific focus on the efficacy and usability of
system, thereby involving physical attitude and nutritional these tools and (2) to summarize the principal instruments as
behaviors, by increasing the capacity to control blood glucose well as their psychometric characteristics to assess psychological
[17]. Individuals with T2DM require continuous monitoring by symptoms related to T2DM, with a focus on symptoms of
health care professionals regarding the organic effects of anxiety, stress, and depression, through the use of technology.
diabetes; conversely, anxiety, depression, and especially stress
symptoms often remain unrecognized and therefore untreated Methods
[18]. Previous studies have shown that these psychological
symptoms increase the risk of more negative outcomes related Study Design
to diabetes, such as glycemic control and impaired This literature review sheds light on the types of technological
cardiovascular functioning [19]. Indeed, authors have suggested devices through which psychological instruments were used to
integrating psychological and medical care to address assess psychological distress among adults with T2DM. This
psychological symptoms and unhealthy habits (ie, sedentary review was conducted through the academic databases PubMed
lifestyle, poor diet), which often accompany depression, anxiety, (360 articles), PsycINFO (165 articles), and CINAHL (239
and stress, as they seem to implicate benefits regarding the articles) in which the following terms and their derivatives were
disease itself [6], the patients’ quality of life, and their considered during the search: diabetes mellitus, measure,
psychological well-being. Therefore, early detection and prompt assessment, self-care, self-management, depression, anxiety,
treatment of anxiety, depression, and stress symptoms can lead stress, technology, eHealth, mobile health, mobile phone, device,
to a better medical prognosis and a better quality of life for and smartphone. More specifically, the terms self-care and
individuals with T2DM. For instance, patients with this disease self-management have been used as search words to find articles
who have received psychological interventions have shown an in which technological devices are mentioned. Moreover,
increase in satisfaction with treatment [20]. Therefore, as a first according to the Cambridge Dictionary, the term device refers
step, it is important to identify valid tools that can assess the to a machine, for instance, a phone or a computer, which can
levels of anxiety, depression, and stress related to T2DM be used to connect to the internet [23]. In this review, these
management to define the appropriate treatment. Within this search terms were used to identify devices suitable for assessing
framework, technological devices for supporting self-care in psychological distress in T2DM. We began the review with an
patients with T2DM are increasing globally [21]. In particular, examination of the types of technologies through which
these instruments are mainly focused on monitoring blood psychological questionnaires were administered and continued
glucose and physical activities through several technological by examining the principal instruments for assessing
devices. The use of technological apps helps support people psychological symptoms related to T2DM. We then concluded
with T2DM in the management of their psychological distress the review by providing directions for future work and clinical
and stress. However, although studies to date have shown implications.
promising results in the use of smartphone apps for diabetes

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Inclusion Criteria moods and their patterns over time. The research question
The studies included in the review were in line with the concerning the efficacy and usability of the tools has not found
following inclusion criteria: (1) presence of technological a clear and complete answer. It seems that this research question
support for mental health assessment delivered to patients with was not fully addressed in previous research but just tangentially
T2DM; (2) studies with at least 60% of participants with T2DM, touched on or inferred as a parallel finding.
in order to have most people with only T2DM, the target Advantages and Disadvantages of Technological
population of this study; (3) studies that focused on depression, Devices
anxiety, stress, or other psychological symptoms in patients
with T2DM; and (4) samples comprising adults aged between The use of information and communication technology (ICT)
18 and 70 years who may present with psychological distress, apps in health care settings is increasing globally. Indeed, a
with a focus on depression, anxiety, and/or stress symptoms useful way of communicating preventive methods to the
related to T2DM. population is through ICT [42,43]. This is motivated by an
interest in facilitating active participation for people to
Exclusion Criteria self-manage their health as well as by the need to develop apps
Studies that met any of the following criteria were excluded: and platforms, which can be more cost-effective, compared with
(1) absence of technological support for mental health traditional approaches, and also to manage chronic conditions,
assessment; (2) studies involving patients with other chronic such as diabetes [44,45]. For instance, the ATA or automated
conditions or primary diseases (eg, cardiovascular disease, telephone communication systems is an app used to deliver both
cardiomyopathy, chronic kidney disease) or psychiatric preventive health care programs and services to manage chronic
disorders, according to the Diagnostic and Statistical Manual conditions. Several studies have analyzed the ATA system for
of Mental Disorders, 5th Edition [24]; (3) presence of the management of diabetes [46,47], heart failure [48,49],
individuals with the risk of T2DM onset; (4) studies that focused coronary heart disease [50], and asthma [51] as well as for
only on monitoring glycemic control or physical activity in health-promoting methods, including dietary behavior [52,53]
patients with T2DM; (5) presence of cognitive dysfunction in and physical activity [54,55]. ATA can deliver voice messages
patients with T2DM; (6) samples based only on individuals and gather health-related information from patients using voice
with type 1 diabetes mellitus; (7) studies that took into account recognition programs or touch-tone telephone [56], in addition
samples of children and adolescents and/or parents supporting to, or instead of, the telephone interaction between health
their children with diabetes; and (8) studies that focused on professionals and patients. In particular, ATA has 3
pregnant women with diabetes. subcategories: (1) unidirectional ATA, which enables one-way,
noninteractive voice communication, including, for instance,
Results interventions such as automated reminder calls to take
medication; (2) the IVR system, which is the most common
Included Studies form of two-way real-time communication, allowing automated
tailored feedback based on the monitoring of an individual’s
On the basis of the inclusion and exclusion criteria, 17 articles
progress, thereby allowing one-to-one interventions [56,57];
were eligible for the literature review.
and (3) ATA with additional functions, namely ATA Plus, such
Types of Technologies Through Which Tools Were as access to an expert to request support and ask questions via
Administered telephone or face-to-face meetings, and also the delivery of
Most studies (6 articles) were conducted in paper-based automated, nonvoice communications such as SMS text
format—at baseline and follow-up—through written messages or email [58]. ATA—conceived as a data collection
questionnaires provided by the staff or employing interviews tool—presents several advantages compared with the classical
before the technological intervention to evaluate the face-to-face assessment [59], such as simplicity, anonymity,
psychological distress and health-related quality of life of and low costs [56,60]. Therefore, ATA can allow access to
patients with T2DM [25-30]. Furthermore, 4 studies health care systems 7 days a week for 24 hours a day, together
administered self-reports through the automated telephonic with immediate feedback to the patient [61,62]. Indeed, studies
assessment (ATA), a call system for screening and monitoring reported higher levels of user satisfaction experience, suggesting
that is tailored on patients’ conditions and preferences [31-34] that it is accessible for both patients and health care
or in 1 study through telephone interviews via the interactive professionals [62]. Unlike face-to-face interactions, which can
voice response (IVR) call self-management support program evoke socially acceptable answers, leading to the underreporting
(ie, tailored messages, structured email) [35]. In addition, in 2 of stigmatizing behaviors and overreporting of socially desirable
studies, tools were administered through simple telephone behaviors, ATA can elicit better self-reporting of specific and
interviews [36,37]. In 1 study, questionnaires were delivered sensitive problems (eg, alcohol and substance use) and reduce
through tablets available from a site to assess the psychological self-reporting bias [63] as well as health care delivery costs
well-being of patients [38], whereas another study used a mobile [64,65]. On the other hand, ATA may also have disadvantages
app [39]. Furthermore, 3 studies were conducted using the mood such as the difficulty in catching, interpreting, or responding to
rating scale, which consists of asking the patient “how do you patients’ nonverbal answers to the interview questions [63,66].
feel?” through a tailored text message–based diabetes support Moreover, people with physical disabilities can have difficulty
system (ie, tablets, mobile phone) [38,40,41]. Specifically, the in using ATA [67], and some people can prefer face-to-face
mood rating scale is integrated into the technology to evaluate interaction rather than ATA [68]. In this framework, the classical

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telephone interviews, unlike the ATA system, can allow possible to ensure that the scales were used to address diabetes.
researchers and clinicians to obtain additional indications from In contrast, studies that administered the Diabetes Distress
the emphasis, intonation, hesitations, and the words used. Scale-17 (DDS-17) [3] to evaluate diabetes-specific distress in
However, as with the ATA system, they may have difficulty the management of the disease reported that this tool shows
understanding the nonverbal responses. Telephone interviews good reliability and internal validity of the measure across
also include limited telephone coverage in specific areas and independent samples [28,33,36,38]. This is the only scale that
lower response rates [69]. On the other hand, health has been validated specifically for diabetes distress, focusing
professionals who use telephone interviews as assessment tools on problems that those patients may experience, such as
also have the opportunity to request a follow-up. Other digital emotional burden, interpersonal distress, or regimen-related
solutions mentioned in this review are mobile phones, tablets, distress [3].
and desktop computers, in which mobile phone apps can allow
Another instrument that is widely used to assess depressive
real-time tracking of mood status, for instance, in patients with
symptoms through technologies is the Patient Health
diabetes [70], anywhere and at any time, and they are
Questionnaire-9 (PHQ-9); indeed, 9 studies administered the
particularly suitable for delivering immediate feedback, which
above questionnaire [25-28,31-34,38]. The Centers for Medicare
makes them preferable to tablets and desktop computers.
and Medicaid Services recommend the use of the PHQ-9 for
Moreover, besides being able to send voice and text messages,
home health care patients. The PHQ-9 was tested in primary
mobile phones present more advanced features, such as web
care, demonstrating clinical relevance in relation to the
searching, high-quality cameras, a GPS, and sound recording.
Diagnostic and Statistical Manual of Mental Disorder-IV-Text
Altogether with strong processors and operating systems, large
Revision [24,78]. The PHQ-9 further comprises 2 components:
memories, and high-resolution screens, mobile phones have
symptoms and functional impairment assessment, which is
turned into handheld computers. In particular, the use of mobile
useful for diagnosis, and a severity score, which is useful for
phones is increasing in health care settings (defined as mobile
selecting and monitoring treatments [26,27,32,38]. In addition,
health [mHealth]), allowing health professionals to provide easy
1 study that administered the PHQ-8, a standardized and
and rapid access to updated medical information [71,72]. Indeed,
validated scale, showed its good reliability in assessing
a great number of mHealth apps have become useful tools for
depressive symptoms [37]. Therefore, the PHQ represents a
health professionals, including health record maintenance and
good tool to assess depressive symptoms in chronic diseases,
access, clinical software apps for suggestions within disease
including T2DM, as shown by its wide use. With regard to other
diagnosis, patient management and monitoring, clinical decision
psychological symptoms examined in the included studies, the
making, and medical training [71,73,74]. Moreover, mHealth
tools used to assess anxiety symptoms were few, although the
has been found to support better clinical decision making and
literature highlighted how anxiety could influence the chronic
improve patient health outcomes [74,75]. On the other hand,
disease itself [79] to a higher degree than depressive disorders.
one major issue concerns the security of health information
In this context, 1 study administered the Hospital Anxiety and
delivered via mobile phones. mHealth adopts wireless
Depression Scale-14 items [80] to assess anxiety and depression
atmospheric media to transmit data in the form of radio signals,
symptoms [40], and 2 studies [30,35] evaluated depression
which seem to be vulnerable to hackers and therefore to
symptoms using the Center for Epidemiological Studies
modification or distortion [76]; moreover, mHealth is closely
Depression Scale [81]. Furthermore, 2 other studies [31,33]
networked with other wireless devices [77]. However, most
analyzed depression symptoms using the Hopkins Symptom
professionals think that mHealth could significantly improve
Checklist Depression-20 [82]. With regard to the evaluation of
health care delivery processes, thereby improving patients’
the emotional distress experienced by people with diabetes, 2
psychophysical health. Indeed, mHealth interventions can reduce
studies [27,35] administered the Problem Areas in Diabetes
costs, save time, facilitate access to medical information, and
[83]. Furthermore, 2 studies administered the Brief Symptom
provide a simpler and quicker way for patients and clinicians
Inventory [84] to assess a wide range of psychological symptoms
to send medical communications. Therefore, the adoption of
[33,36]. Stress symptoms were evaluated using a psychological
mHealth improves the lifestyle, nutrition, behaviors, and quality
scale through the mood rating; this was found to be interesting,
of life of people with various diseases, particularly with chronic
as this scale is a technological modality to assess the nature of
conditions. Thus, mHealth is increasingly considered to be one
mood, thereby giving special importance to the monitoring
of the best digital solutions for the support of individuals in the
instead of the screening of these symptoms [38,40,41]. The
management of their disease and the improvement of their health
most used self-reports through technologies evaluating diabetes
conditions [77].
quality of life can be grouped into 3 categories: one refers to
Principal Instruments to Assess Psychological pain that can interfere with normal work and the other 2
Symptoms in T2DM in the Technology Field categories refer to the physical and emotional symptoms related
to the quality of life as assessed through the Medical Outcome
Most studies included in the review reported only the name of
Study Short-Form (MOS-SF) Health Survey 12 and 36 items
the instrument, thereby not providing information regarding the
[85,86], respectively, which are considered to be reliable and
psychometric properties of the tools, such as reliability, validity,
valid scales [26]. Overall, 6 studies administered the short
data monitoring, contextual collection, and/or whether the
version of the MOS [30,31,34,35,39,40] and 2 studies
instrument was specified for the population with diabetes
administered the longer version [25,38]. One study [26]
[28,31,33-36,38,40]. In addition, the reasons for using such
evaluated the self-perception of quality of life through the
tools were not described in the analyzed papers; thus, it was not
EuroQol-5 Dimension [87], which has been tested and validated
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to capture the difference in the quality of life in patients with individual has of their capacity to produce the desired results
chronic diseases [28]. One study [29] analyzed the healthy necessary to influence events, thereby affecting their lives [30].
self-management of the disease itself through the Health Indeed, in the context of T2DM diabetes, a study found that
Education Impact Questionnaire [88], and it has also been higher glycemic control is associated with better self-efficacy
validated in a primary health care context with patients with and self-care behaviors [90].
several chronic conditions, including diabetes [29]. Therefore,
A summary of the types of technological solutions through
it seems that these studies used tools specifically targeted to
which patient screening and psychological assessment were
patients with chronic diseases, including diabetes, to evaluate
conducted is presented in Multimedia Appendix 1 [25-41]. In
their quality of life as they had to change their physical and
addition, Textbox 1 shows the advantages and disadvantages
psychological habits. It is worth noting that one of the variables
of administering questionnaires in paper-and-pencil form versus
that emerged after the revision of the included studies was
those in digital form. Furthermore, all the questionnaires used
self-efficacy. Self-efficacy is a key variable in the proper
to assess psychological symptoms in patients with T2DM are
management of diabetes within the health care setting [89].
described in-depth in Multimedia Appendix 2 [3,79,82-90].
Indeed, it represents the awareness and the perception that each

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Textbox 1. Advantages and disadvantages of administering paper-and-pencil questionnaires versus administering questionnaires through digital solutions.
Paper-and-pencil questionnaires

• Advantages

• More cost-effective when surveying data in small samples

• Could increase a working alliance because of human interaction

• Benefits people who do not have internet access

• More favorable format when it comes to longer questionnaires

• No digital skills are required to answer

• Disadvantages

• Lack of immediate data analysis

• Data entry is needed to store them in databases

• Handwritten responses could be difficult to interpret, especially when it comes to open-ended questions

• Needs longer data processing

• Printing and archiving of the questionnaires are needed

• There is the option of skipping questions

• Human errors can occur when updating the database

Questionnaires through digital solutions

• Advantages

• Save time for clinicians and researchers

• Faster in delivering the questionnaires

• Directly collect data on the web

• Furnish an immediate feedback

• Collect data from people around the world

• More ecological (ie, no printing and other costs at the point of completing setup)

• Better graphic layout (ie, not only color images and text, but also dynamic and interactive animation)

• Collect all the responses, thereby avoiding unanswered questions

• Allows longer answers to open-ended questions

• Gives more time to fill in the questionnaires

• Disadvantages

• Familiarity with digital devices is required

• Possible difficulties for data analysis derived from people filling-in the questionnaire multiple times, which would bias the results

• Lack of technological devices

• Technical problems

• Unreliable network

self-care should be multidimensional, including treatment for

Discussion both organic and psychological symptoms, whereas at the same
Principal Findings time, it should use technology-based tools, which show good
psychometric properties and are validated by samples of patients
This study aimed to review past literature regarding the types with chronic diseases.
of technological devices used to administer psychological
instruments for assessing psychological distress (ie, depressive, First, studies seem to focus on the evaluation of psychological
anxiety symptoms) and stress in patients with T2DM. Assessing distress and diabetes-specific distress, particularly anxiety,
diabetes-related psychological symptoms can be challenging, depression, and stress symptoms. Indeed, instruments that
due in part to the complexity of diabetes care. Indeed, diabetes measure symptoms of anxiety, stress, and depression related to

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T2DM, administered through technologies, were analyzed, and and for problems often experienced by these patients, such as
their efficacy and usability were evaluated. In this context, the emotional burden, interpersonal distress, or regimen-related
psychometric properties of the instruments are prerequisites for distress [3]. Another widely used instrument is the MOS-SF-12,
an accurate assessment of psychological distress in patients with which assesses the physical and emotional symptoms related
diabetes. Inadequate reliability and validity of the tools make to the quality of life.
it difficult to detect the psychological well-being of patients
Moreover, considering the importance of the role of self-efficacy
with diabetes and the impact of interventions on their well-being
in the management of emotion-related diabetes, it is
or quality of life. Here, the timing of the test can influence its
recommended that researchers and clinicians use specific tools
reliability and validity, and therefore it needs to be taken into
to address self-efficacy in those patients. Of particular note is
consideration. Within a longitudinal evaluation of an
the fact that most studies used psychological tools in the
intervention, if the duration of the test was too short, participants
standard paper format to assess the effectiveness of interventions
could recall information from the first time they completed it,
without integrating them into digital solutions. Indeed, in this
which could bias the findings. Alternatively, if its duration was
review, few studies delivered web-based questionnaires [38,39].
too long, participants may have changed significantly, which
As an example, the Meru Health Ascend, a smartphone-based,
could also bias the results [91].
therapist-supported intervention for depression and anxiety in
In most studies, screening was conducted using written patients with no chronic disease, delivered 2 validated scales
questionnaires at baseline and after a follow-up as well as for psychological distress (ie, PHQ-9 and the Generalized
telephone interviews (ie, simple telephone interviews, ATA Anxiety Disorder-7) on a smartphone [102].
calls, and IVR) to assess psychological symptoms [25-32,36,37].
In this study, the integration of assessment instruments in digital
Few studies have used digital solutions, such as mobile apps, solutions improved the assessment of depressive and anxiety
tablets, and computers, to deliver psychological self-reports for symptoms. Thus, research suggests that mHealth interventions
intervention groups, even though they were investigating the are functional ways of supporting the treatment of depression
psychological symptoms related to the disease itself and anxiety symptoms [102].
[26,31,33,35-39,84]. In this context, the recent progress in
technologies supports the ecological momentary assessment of
Limitations and Strengths
mood, using mood ratings through mobile devices, outside the This review presents some limitations, as it included only papers
clinical environment. The mood rating scale can help to bypass in English, which limits the generalization of the findings. In
issues associated with infrequent reporting of depressive addition, a limitation could be identified in the different
symptoms and allows for a better representation of the dynamic implications regarding the use of technological devices from
nature of mood, which is often left unreported, and to better the age of 18 to 70 years. Older adults may be less familiar with
guide treatment planning [92,93]. For instance, delivering the use of these devices. Future work should evaluate the effect
psychological instruments through technologies (eg, mobile of the use of technological devices among individuals of
phone apps) allows researchers to collect data directly from the different ages. In the context of digital solutions, the
web; thus, the wide use of the mood rating strategy would disadvantage of smartphone-, tablet-, or computer-based apps
suggest saving time [94,95]. For instance, some studies have is that they can be removed by the user; however, such
analyzed the feasibility of daily or weekly SMS text messages device-based apps and other conversational agents can represent
based on mood ratings, showing that mood ratings represent a a valuable solution in administering psychological tools for the
valid monitoring strategy for patients with depression [70,96,97]. screening of patients, especially in emergency situations such
Mobile phone apps allow real-time tracking of mood status in as the SARS-CoV-2 pandemic. Furthermore, most studies do
patients with T2DM [70], anywhere and at any time, and they not provide information regarding the psychometric properties
are particularly suitable for delivering immediate feedback of tools, such as reliability, validity, and contextual collection.
(which makes them preferable to tablets and desktop computers). It could be important to include such characteristics to better
Moreover, they facilitate data collection in a more understand the instruments used for assessing psychological
contextualized, pervasive, longitudinal, and reliable way, rather distress and diabetes-specific distress. Another limitation is the
than using written questionnaires (preintervention and noninclusion of videoconference calling as a digital solution,
postintervention). In addition, they allow adapting the which especially during the COVID-19 lockdown represented
intervention to patients’ needs, supporting them in the the method of choice among practitioners in psychology and
management of their chronic disease. On the basis of other psychiatry for a remote assessment of mental health. Future
chronic diseases, mobile phone apps can provide studies should include these types of technological solutions to
psychoeducation [98], smoking cessation support [99], cognitive expand this literature review.
behavioral therapy [100], and support to caregivers [101]. Finally, the focus of the review was only on psychological
Therefore, the identification of the appropriate psychological measures related to T2DM. In future works, one would
tools that can be embedded in digital devices, such as recommend the integration of the assessment and monitoring
smartphones, could allow researchers and clinicians to conduct of both organic and psychological symptoms in patients with
a screening of the level of anxiety, stress, and depressive T2DM.
symptoms in patients with T2DM in a faster and easier way.
Second, the PHQ-9 and the DDS-17 emerged as useful tools
for the assessment of depressive symptoms in chronic diseases
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On the other hand, this review also has some strengths. In conditions. For example, the mood rating scale is widely used
addition to depression, the review considered all possible in studies to assess diabetes-related stress and depression.
psychological symptoms related to T2DM. Therefore, the identification of appropriate psychological tools
that can be deployed through mHealth solutions allows
Future Development and Implications of the Study researchers and clinicians to screen for anxiety, stress, and
This review highlighted implications that may have an impact depression in patients with T2DM in a faster and easier way.
on future research and clinical practice. In particular, the use of Moreover, data from the literature suggest that mHealth
appropriate technological solutions to assess the psychological interventions are preferable to other types of digital interventions
condition of patients can allow early detection of depression, [101]. For instance, mHealth apps have recently been deployed
stress, and anxiety symptoms, especially in chronic conditions in the field of psychology to deliver evidence-based treatments
as well as mental disorders [103]. In less severe cases, it might for depression and anxiety and to overcome barriers of
also help the deployment of mHealth interventions to support face-to-face psychotherapy [101]. Therefore, this study can add
and improve depression, anxiety, and stress symptoms in T2DM to the scientific body of literature on the revision of valuable
to lower the burden for the health care system, in a stepped care digital solutions in assessing and monitoring the mental health
approach [104]. Previous research found that mHealth solutions of patients, in which the traditional paper-and-pencil instruments
were well accepted by young adults [105], and further research can be delivered through digital solutions. Indeed, administering
is required to assess their acceptability by older adults with questionnaires through technological devices is a more
T2DM. Furthermore, because of the huge growth of mHealth cost-effective, time-efficient method for data gathering and for
apps, it would be useful to screen the levels of anxiety, stress, real-time tracking of mood status. Effective programs for chronic
and depression symptoms in patients with diabetes, using disease management should combine relevant information
appropriate psychological instruments. This screening could be systems, with constant follow-up and targeted self-management
able to identify whether the patient showed mild, moderate, or for patients. In this way, ICT is incorporated in such a way as
severe symptoms, thereby allowing clinicians to better set up to provide accessible and convenient psychoeducational
interventions. information as well as self‐management tools for people with
long-term conditions. Finally, it is worth noting that ICT
Conclusions
represents the only feasible way to assist and maintain health
In view of the large increase in the number of patients with care, in chronic and nonchronic disease, in such a dramatic
diabetes globally, it is important to intensify efforts in the period as the actual pandemic, and thus gaining better
deployment of digital solutions for the accurate assessment of knowledge and flexibility in the use of these methods becomes
patients’ psychological condition. These instruments can be essential.
useful for clinicians and researchers to better monitor patients’

Conflicts of Interest
None declared.

Multimedia Appendix 1
Articles from the literature review.
[DOCX File , 25 KB-Multimedia Appendix 1]

Multimedia Appendix 2
Description of the psychological instruments.
[DOCX File , 22 KB-Multimedia Appendix 2]

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Abbreviations
ATA: automated telephonic assessment
DDS-17: Diabetes Distress Scale-17
ICT: information and communication technology
IVR: interactive voice response
mHealth: mobile health
MOS-SF: Medical Outcome Study Short-Form Health Survey
PHQ-9: Patient Health Questionnaire-9
T2DM: type 2 diabetes mellitus

Edited by G Eysenbach; submitted 09.01.20; peer-reviewed by D Di Riso, R Ho, R Barak Ventura; comments to author 10.03.20;
revised version received 05.08.20; accepted 11.11.20; published 07.01.21
Please cite as:
Bassi G, Gabrielli S, Donisi V, Carbone S, Forti S, Salcuni S
Assessment of Psychological Distress in Adults With Type 2 Diabetes Mellitus Through Technologies: Literature Review
J Med Internet Res 2021;23(1):e17740
URL: https://www.jmir.org/2021/1/e17740
doi: 10.2196/17740
PMID: 33410762

©Giulia Bassi, Silvia Gabrielli, Valeria Donisi, Sara Carbone, Stefano Forti, Silvia Salcuni. Originally published in the Journal
of Medical Internet Research (http://www.jmir.org), 07.01.2021. This is an open-access article distributed under the terms of the
Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution,
and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is
properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this
copyright and license information must be included.

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