patients with type 2 diabetes and dd were recruited from the patient registries of several community medical groups and diabetes education centers . inclusion criteria were a registry - recorded diagnosis of type 2 diabetes 12 months , a mean score of 1.5 on the two - item diabetes distress screener ( 19 ) ( confirmed later by the full scale ) to indicate at least moderate dd ( 2,20 ) , age 21 years , ability to read and speak english , at least moderate computer use facility , easy availability of a computer with internet access , comfort with internet use , and self - reported problems with diabetes management ( healthy eating or exercise plan not followed in 3 of 4 days during the previous week or medications not taken 2 or more days during the previous week , based on the summary of diabetes self - care activities ) . exclusion criteria included clinical depression ( patient health questionnaire 8 score 15 ) and severe diabetes complications or functional deficits ( e.g. , dialysis , blindness).patients received a letter from their health care facility , signed by a facility clinician and project representative , informing them of the project . they were told that a redeem representative would telephone them to explain the project further unless they opted out by calling an 800 number or by returning an enclosed postcard . during a follow - up call , the project was explained , patients were screened , and eligible patients were invited to a meeting at our project office or at another convenient location ( e.g. , library , patient s home ) . at the meeting , eligibility requirements were confirmed , informed consent was obtained , and a 1.5-h baseline assessment was completed ( a0 ) that included height and weight , questionnaires , brief interview , and visit to a community laboratory for collection of biological data . patients were then randomized individually to one of the three study arms using a computer - generated algorithm , and an intervention visit was scheduled within 2 weeks . in keeping with a pragmatic design and comparative effectiveness research ( 23 ) , no usual care condition was included because of concerns about maintaining highly distressed patients in a noninterventional study arm . assessments were repeated at 4 ( a4 ) and 12 ( a12 ) months postintervention . three nonprofessional college graduate interventionists were trained and closely supervised by the investigators to deliver each of the three interventions and the telephone calls . a separate team of assistants undertook a0 , a4 , and a12 assessments . patients randomized to casm were introduced to  my path to a healthy life ,  a 40-min , previously validated , web - based diabetes self - management improvement program ( 16,24 ) . patients selected achievable goals for medication adherence , diet , or exercise and were shown how to monitor their daily progress on the site . the predominately web - based intervention also provided an ask - the - expert forum to enhance engagement ( 25 ) . patients received four live phone calls from their interventionist at weeks 2 , 4 , 7 , and 12 to check progress and problems regarding their use of casm and to provide encouragement to continue their efforts . at month 5 , patients received an automated  behavior chain this interactive component involved illustrative scenarios of prototypic patients experiencing  chains of events , e.g. , negative thinking that triggered overeating , followed by an exercise to help  break  the sequence ( 7,10 ) . finally , patients received four more live 15-min phone calls at weeks 24 , 28 , 34 , and 48 . patients randomized to caps received a 60-min in - person intervention that included casm plus pst . pst is an eight - step process to identify and define dd , establish realistic goals , generate ways to meet these goals , weigh the pros and cons of each , choose and evaluate solutions , create a dd action plan , evaluate outcome , and engage in pleasant activities ( see pstnetwork.ucsf.edu ) ( 26,27 ) . as in casm , caps patients received four live phone calls between a0 and a4 and between a4 and a12 to check progress on casm and pst , respond to problems , and provide encouragement and a live supplemental booster session at month 5 ( a review of the pst steps ) . patients randomized to leap ahead , a minimal intervention in comparison with the other two conditions , received a 20-min , computer - delivered health risk appraisal ( e.g. , seat belt and sunscreen use ) along with diabetes information regarding healthy living , diet , and physical activity ( 28 ) preceding each of the eight calls between a0 and a12 . the materials delivered diabetes information only , and patients were not directed to use the information to engage in a specific or structured program of self - management or dd change . patients received a repeat of the risk appraisal at month 5 , the same number and sequence of subsequent live phone calls to answer questions about provided diabetes management information , and assessments similar to those of casm and caps . the university of california , san francisco , institutional review board and the committees of collaborating institutions approved this study . patient demographic variables included age ( continuous variable ) , sex , race ( white vs. nonwhite ) , and education ( years ) ; diabetes status included use of insulin ( yes vs. no ) , years since diagnosis , and number of comorbidities and complications derived from a list of 22 common diabetes - related health problems . the primary dependent variable was dd , which was assessed by the 17-item diabetes distress scale ( dds ) ( 20 ) (  = 0.87 ) , the five - item regimen distress ( rd ) dds subscale (  = 0.90 ) , and the five - item emotional burden ( eb ) dds subscale (  = 0.88 ) . rd and eb were selected because they were directly targeted by the interventions . items that reflect areas of distress are rated on a 6-point likert scale from  not a problem  to a  very serious problem . rd items include feeling that i am often failing with my diabetes regimen and feeling that i am not sticking closely enough to a good meal plan ; eb items include feeling overwhelmed by the demands of living with diabetes and feeling that diabetes controls my life . mean item scores from 2.0 to 2.9 reflect moderate distress , and scores 3 are considered high distress ( 2 ) . physical activity was assessed by the community health activities model program for seniors ( 29 ) . it measures weekly caloric expenditure of light , moderate , and heavy physical activity . only the light physical activity variable was used in the present analyses because it most frequently reflected levels reported by patients . healthy eating was assessed by the nci percent energy from fat screener ( 30 ) , which estimates percent energy ( calories ) from fat based on consumption of 14 foods . medication adherence was assessed by the eight - item hill - bone compliance scale (  = 0.80 ) ( 31 ) that assesses how often and why respondents miss taking medications , rated on a 4-point scale from  none of the time  to  all of the time . glycemic control was assessed by hba1c , which was analyzed in a central laboratory for all participants and natural log transformed to reduce skew and kurtosis . missing data were imputed with multiple imputation procedures using norm , version 2 , software ( 32 ) . norm imputes data via an expectation - maximization algorithm , which provides efficient estimation of mean , variances , and covariances and uses a data - augmentation procedure that generates multiple imputations of missing values . variables within a limited range were logit transformed to ensure that imputed values also fell within that range . one - way anova and  tests , as appropriate , were conducted to test for baseline differences across the three treatment conditions and to examine differences in outcomes between dropouts and continuing participants . repeated - measures anova models were used to test for change across time in the outcome variables ( dds , rd , eb , light physical activity , fat intake , medication adherence , and log - transformed hba1c ) . difference scores were calculated for outcomes , with earlier scores subtracted from later scores : a0a4 , a0a12 , and a4a12 . for each difference - score outcome , a series of anova models was specified to test for main treatment effects both in the absence of and with covariates , main effects of treatment and predictors , and interactions between intervention group and baseline demographic variables , disease status variables , and baseline value of outcome . given the large number of interactions tested , only variables for which a consistent pattern of significant interaction terms emerged were retained in the final models . patients randomized to casm were introduced to  my path to a healthy life ,  a 40-min , previously validated , web - based diabetes self - management improvement program ( 16,24 ) . patients selected achievable goals for medication adherence , diet , or exercise and were shown how to monitor their daily progress on the site . the predominately web - based intervention also provided an ask - the - expert forum to enhance engagement ( 25 ) . action plan  for each previously prioritized management problem . also included was a list of personalized barriers and strategies to overcome barriers . patients received four live phone calls from their interventionist at weeks 2 , 4 , 7 , and 12 to check progress and problems regarding their use of casm and to provide encouragement to continue their efforts . at month 5 , patients received an automated  behavior chain  booster program to reduce negative behavioral practices . this interactive component involved illustrative scenarios of prototypic patients experiencing  chains of events , e.g. , negative thinking that triggered overeating , followed by an exercise to help  break  the sequence ( 7,10 ) . finally , patients received four more live 15-min phone calls at weeks 24 , 28 , 34 , and 48 . patients randomized to caps received a 60-min in - person intervention that included casm plus pst . pst is an eight - step process to identify and define dd , establish realistic goals , generate ways to meet these goals , weigh the pros and cons of each , choose and evaluate solutions , create a dd action plan , evaluate outcome , and engage in pleasant activities ( see pstnetwork.ucsf.edu ) ( 26,27 ) . as in casm , caps patients received four live phone calls between a0 and a4 and between a4 and a12 to check progress on casm and pst , respond to problems , and provide encouragement and a live supplemental booster session at month 5 ( a review of the pst steps ) . patients randomized to caps received a 60-min in - person intervention that included casm plus pst . pst is an eight - step process to identify and define dd , establish realistic goals , generate ways to meet these goals , weigh the pros and cons of each , choose and evaluate solutions , create a dd action plan , evaluate outcome , and engage in pleasant activities ( see pstnetwork.ucsf.edu ) ( 26,27 ) . as in casm , caps patients received four live phone calls between a0 and a4 and between a4 and a12 to check progress on casm and pst , respond to problems , and provide encouragement and a live supplemental booster session at month 5 ( a review of the pst steps ) . patients randomized to leap ahead , a minimal intervention in comparison with the other two conditions , received a 20-min , computer - delivered health risk appraisal ( e.g. , seat belt and sunscreen use ) along with diabetes information regarding healthy living , diet , and physical activity ( 28 ) preceding each of the eight calls between a0 and a12 . the materials delivered diabetes information only , and patients were not directed to use the information to engage in a specific or structured program of self - management or dd change . patients received a repeat of the risk appraisal at month 5 , the same number and sequence of subsequent live phone calls to answer questions about provided diabetes management information , and assessments similar to those of casm and caps . the university of california , san francisco , institutional review board and the committees of collaborating institutions approved this study . patient demographic variables included age ( continuous variable ) , sex , race ( white vs. nonwhite ) , and education ( years ) ; diabetes status included use of insulin ( yes vs. no ) , years since diagnosis , and number of comorbidities and complications derived from a list of 22 common diabetes - related health problems . the primary dependent variable was dd , which was assessed by the 17-item diabetes distress scale ( dds ) ( 20 ) (  = 0.87 ) , the five - item regimen distress ( rd ) dds subscale (  = 0.90 ) , and the five - item emotional burden ( eb ) dds subscale (  = 0.88 ) . items that reflect areas of distress are rated on a 6-point likert scale from  not a problem  to a  very serious problem . rd items include feeling that i am often failing with my diabetes regimen and feeling that i am not sticking closely enough to a good meal plan ; eb items include feeling overwhelmed by the demands of living with diabetes and feeling that diabetes controls my life . mean item scores from 2.0 to 2.9 reflect moderate distress , and scores 3 are considered high distress ( 2 ) . physical activity was assessed by the community health activities model program for seniors ( 29 ) . it measures weekly caloric expenditure of light , moderate , and heavy physical activity . only the light physical activity variable was used in the present analyses because it most frequently reflected levels reported by patients . healthy eating was assessed by the nci percent energy from fat screener ( 30 ) , which estimates percent energy ( calories ) from fat based on consumption of 14 foods . medication adherence was assessed by the eight - item hill - bone compliance scale (  = 0.80 ) ( 31 ) that assesses how often and why respondents miss taking medications , rated on a 4-point scale from  none of the time  to  all of the time . glycemic control was assessed by hba1c , which was analyzed in a central laboratory for all participants and natural log transformed to reduce skew and kurtosis . descriptive statistics were computed to review score distributions . missing data were imputed with multiple imputation procedures using norm , version 2 , software ( 32 ) . norm imputes data via an expectation - maximization algorithm , which provides efficient estimation of mean , variances , and covariances and uses a data - augmentation procedure that generates multiple imputations of missing values . variables within a limited range were logit transformed to ensure that imputed values also fell within that range . one - way anova and  tests , as appropriate , were conducted to test for baseline differences across the three treatment conditions and to examine differences in outcomes between dropouts and continuing participants . repeated - measures anova models were used to test for change across time in the outcome variables ( dds , rd , eb , light physical activity , fat intake , medication adherence , and log - transformed hba1c ) . difference scores were calculated for outcomes , with earlier scores subtracted from later scores : a0a4 , a0a12 , and a4a12 . for each difference - score outcome , a series of anova models was specified to test for main treatment effects both in the absence of and with covariates , main effects of treatment and predictors , and interactions between intervention group and baseline demographic variables , disease status variables , and baseline value of outcome . given the large number of interactions tested , only variables for which a consistent pattern of significant interaction terms emerged were retained in the final models . of 2,606 patients identified from registries whom we could contact , 658 were eligible and 436 agreed to participate ( 66.6% ) ( fig . 1 ) . problems with time and conflicting life demands were the most frequent reasons for nonparticipation . of these , 392 completed baseline assessment and intervention ( 89.5% ) , with 150 randomized to casm , 146 to caps , and 96 to leap ahead . the smaller leap ahead sample was built into the randomization allocation algorithm to provide more power to compare the two active arms . based on telephone screening data , there were no significant differences between those contacted who participated and those who refused . missed  indicates the participant missed the stage , but this did not preclude them from participating in a later stage of the project . attrition was 13.8% from a0 to a4 , 5.7% from a4 to a12 , and 18.7% from a0 to a12 . there were no significant between - group differences in attrition across any time period on any key study variable . there were also no significant baseline differences among the three study groups on any key demographic or diabetes status variable ( table 1 ) . the diverse sample had a mean age of 56  9.6 years ( range 2175 ) , 53.8% of the sample was female , 8.7% of patients had 12 years of education , and mean ( sd ) baseline hba1c was 7.4% ( 1.61 ) ( 57.0 mm / mol [ 17.6 ] ) . baseline characteristics of participants by intervention group ( n = 392 ) significant and clinically meaningful reductions in dds , rd , and eb occurred across the three study groups from a0 to a4 and a0 to a12 ( table 2 ) . also , significant reductions in dd scores between a4 and a12 occurred for all groups both after adjusting and not adjusting for changes between a0 and a4 , indicating continued improvement over time . there were no significant between - group differences in these reductions at any time point for dds , rd , or eb . patients with higher dds , rd , and eb baseline scores consistently displayed the largest reductions in distress from a0 to a4 and a0 to a12 . older patients showed larger reductions in rd and eb than younger patients from a0 to a4 , but younger patients showed larger rd and eb score reductions than older patients from a4 to a12 . predictors of diabetes distress there was a significant group  baseline distress interaction for rd from a0 to a4 such that caps patients with high baseline rd displayed significantly larger rd reductions than high - baseline rd patients in leap ahead ( p = 0.005 ) and marginally larger reductions than those in casm ( p = 0.08 ) . of patients classified as high dd on the dds at baseline ( n = 95 ) , by 12 months thus , categorical changes in dds occurred for 62.1% of initially high dd patients , with no between - group differences ( p = 0.92 ) . among those who displayed moderate dd at baseline ( n = 147 ) , 60.5% reported little or no dd at 12 months . significant reductions in percent of total calories from fat occurred across the entire sample from a0 to a4 and from a0 to a12 but not from a4 to a12 ( table 3 ) . this suggests that gains that occurred primarily during the initial period of the intervention were maintained over time . there was a significant group  baseline percent fat interaction from a0 to a4 and a4 to a12 . caps and leap ahead patients with higher percent fat at baseline demonstrated greater decreases from a0 to a4 than casm patients . the converse was found from a4 to a12 , during which stronger associations were found for casm than leap ahead or caps ( p = 0.02 and p < 0.001 , respectively ) . predictors of behavioral and hba1c outcomes physical activity increased significantly across the entire sample between a0 and a4 and between a0 and a12 but not between a4 and a12 . this suggests that the gains that occurred during the initial part of the intervention were maintained between a4 and a12 . significant treatment group effects were found at a4a12 and a0a12 , indicating that casm and caps patients maintained their a0a4 gains through 12 months , whereas leap ahead patients reverted back toward baseline levels during this period . patients with lower baseline physical activity had the largest increases in physical activity from a0 to a4 and a0 to a12 . from a4 to a12 , there was a significant group  baseline physical activity interaction : among patients with relatively higher baseline physical activity , there were greater reductions in physical activity for patients in leap ahead than in casm ( p = 0.005 ) or caps ( p = 0.05 ) . across the full sample , significant improvements in medication adherence occurred between a4 and a12 and a0 and a12 but not a0 and a4 . these findings suggest that improvements in medication adherence occurred primarily in the later segments of the study . there was a significant a0a12 treatment group effect , indicating that patients in caps had more improvement in medication adherence than those in casm ( p = 0.02 ) and leap ahead ( p = 0.006 ) . patients who were female and who were nonwhite and those with poor baseline medication adherence showed the largest improvements . however , patients who were older ( from a0a4 and a0a12 ) , who had fewer comorbidities / complications ( from a4a12 and a0a12 ) , and who had higher baseline hba1c ( across all time points ) showed the greatest hba1c improvements over time . significant and clinically meaningful reductions in dds , rd , and eb occurred across the three study groups from a0 to a4 and a0 to a12 ( table 2 ) . also , significant reductions in dd scores between a4 and a12 occurred for all groups both after adjusting and not adjusting for changes between a0 and a4 , indicating continued improvement over time . there were no significant between - group differences in these reductions at any time point for dds , rd , or eb . patients with higher dds , rd , and eb baseline scores consistently displayed the largest reductions in distress from a0 to a4 and a0 to a12 . older patients showed larger reductions in rd and eb than younger patients from a0 to a4 , but younger patients showed larger rd and eb score reductions than older patients from a4 to a12 . predictors of diabetes distress there was a significant group  baseline distress interaction for rd from a0 to a4 such that caps patients with high baseline rd displayed significantly larger rd reductions than high - baseline rd patients in leap ahead ( p = 0.005 ) and marginally larger reductions than those in casm ( p = 0.08 ) . of patients classified as high dd on the dds at baseline ( n = 95 ) , by 12 months thus , categorical changes in dds occurred for 62.1% of initially high dd patients , with no between - group differences ( p = 0.92 ) . among those who displayed moderate dd at baseline ( n = 147 ) significant reductions in percent of total calories from fat occurred across the entire sample from a0 to a4 and from a0 to a12 but not from a4 to a12 ( table 3 ) . this suggests that gains that occurred primarily during the initial period of the intervention were maintained over time . older participants and those with higher baseline fat consumption showed the greatest improvements . there was a significant group  baseline percent fat interaction from a0 to a4 and a4 to a12 . caps and leap ahead patients with higher percent fat at baseline demonstrated greater decreases from a0 to a4 than casm patients . the converse was found from a4 to a12 , during which stronger associations were found for casm than leap ahead or caps ( p = 0.02 and p < 0.001 , respectively ) . predictors of behavioral and hba1c outcomes physical activity increased significantly across the entire sample between a0 and a4 and between a0 and a12 but not between a4 and a12 . this suggests that the gains that occurred during the initial part of the intervention were maintained between a4 and a12 . significant treatment group effects were found at a4a12 and a0a12 , indicating that casm and caps patients maintained their a0a4 gains through 12 months , whereas leap ahead patients reverted back toward baseline levels during this period . patients with lower baseline physical activity had the largest increases in physical activity from a0 to a4 and a0 to a12 . from a4 to a12 , there was a significant group  baseline physical activity interaction : among patients with relatively higher baseline physical activity , there were greater reductions in physical activity for patients in leap ahead than in casm ( p = 0.005 ) or caps ( p = 0.05 ) . across the full sample , significant improvements in medication adherence occurred between a4 and a12 and a0 and a12 but not a0 and a4 . these findings suggest that improvements in medication adherence occurred primarily in the later segments of the study . there was a significant a0a12 treatment group effect , indicating that patients in caps had more improvement in medication adherence than those in casm ( p = 0.02 ) and leap ahead ( p = 0.006 ) . patients who were female and who were nonwhite and those with poor baseline medication adherence showed the largest improvements . however , patients who were older ( from a0a4 and a0a12 ) , who had fewer comorbidities / complications ( from a4a12 and a0a12 ) , and who had higher baseline hba1c ( across all time points ) showed the greatest hba1c improvements over time . significant reductions in percent of total calories from fat occurred across the entire sample from a0 to a4 and from a0 to a12 but not from a4 to a12 ( table 3 ) . this suggests that gains that occurred primarily during the initial period of the intervention were maintained over time . older participants and those with higher baseline fat consumption showed the greatest improvements . there was a significant group  baseline percent fat interaction from a0 to a4 and a4 to a12 . caps and leap ahead patients with higher percent fat at baseline demonstrated greater decreases from a0 to a4 than casm patients . the converse was found from a4 to a12 , during which stronger associations were found for casm than leap ahead or caps ( p = 0.02 and p < 0.001 , respectively ) . physical activity increased significantly across the entire sample between a0 and a4 and between a0 and a12 but not between a4 and a12 . this suggests that the gains that occurred during the initial part of the intervention were maintained between a4 and a12 . significant treatment group effects were found at a4a12 and a0a12 , indicating that casm and caps patients maintained their a0a4 gains through 12 months , whereas leap ahead patients reverted back toward baseline levels during this period . patients with lower baseline physical activity had the largest increases in physical activity from a0 to a4 and a0 to a12 . from a4 to a12 , there was a significant group  baseline physical activity interaction : among patients with relatively higher baseline physical activity , there were greater reductions in physical activity for patients in leap ahead than in casm ( p = 0.005 ) or caps ( p = 0.05 ) . across the full sample , significant improvements in medication adherence occurred between a4 and a12 and a0 and a12 but not a0 and a4 . these findings suggest that improvements in medication adherence occurred primarily in the later segments of the study . there was a significant a0a12 treatment group effect , indicating that patients in caps had more improvement in medication adherence than those in casm ( p = 0.02 ) and leap ahead ( p = 0.006 ) . patients who were female and who were nonwhite and those with poor baseline medication adherence showed the largest improvements . however , patients who were older ( from a0a4 and a0a12 ) , who had fewer comorbidities / complications ( from a4a12 and a0a12 ) , and who had higher baseline hba1c ( across all time points ) showed the greatest hba1c improvements over time . regarding our first two research questions , we found that dd and the distress specifically associated with diabetes regimen and emotion management are malleable and highly responsive to intervention . approximately 33% of patients who reported high dd at baseline and 60% of patients who reported moderate dd at baseline reported little or no dd at 12 months . more specifically , we find that interventions that target enhanced self - management ( casm ) reduce dd significantly but that dd - specific interventions ( caps ) may be necessary for patients with initially high levels of rd . rd generates the most distress and displays the greatest distress reduction as a result of intervention . thus , for those with initially high rd ( mean score 3 ) , which is a significant portion of the type 2 diabetes population ( 31.2% ) ( 33 ) , programs that focus on improving disease management alone may be insufficient ; a specific focus on rd may be required . we also find in general that interventions decrease dd , especially rd , the most for patients with initially high dd . because high dd is significantly correlated with poor disease management , hba1c , and functional deficits ( 1 ) , patients displaying these characteristics are at greatest risk for high dd . interestingly , the effects are not moderated by other patient demographic or diabetes - related variables , suggesting that the findings may generalize to most patients with diabetes . furthermore , the pace of reduction in rd as a result of intervention appears different for older and younger patients : older patients show significant reductions in the early phases of the intervention , whereas younger patients respond later . this suggests that younger patients , who may be managing more non  disease - related stresses and life problems ( 34 ) , may require greater exposure to distress - reduction programs over time than older patients . last , we find that reductions in dd are maintained over time . unlike many behavioral programs , in which return to baseline levels over time is common ( 35 ) , reductions in dd can be sustained even with limited patient contact . although several studies show that improved disease management is accompanied by reduced dd ( 10,36,37 ) , younger patients , those with many comorbidities and complications , those with poorer initial functioning , and those having less education may require direct dd assistance . the cumulative effects of multiple stressors , life demands , and functional deficits may place substantive ongoing burdens on patients that reduce internal resources and require more distress - focused attention in clinical care ( 1 ) . reductions in dd were accompanied by significant improvements in healthy eating , physical activity , and medication adherence , although not by change in hba1c , a more distal and nontargeted outcome . thus , even highly distressed , nondepressed patients with type 2 diabetes respond to disease - management interventions . interestingly , consistent with other studies ( 38 ) , improvements in healthy eating and physical activity occur early in the intervention for casm and caps patients and are maintained subsequently without returning to baseline levels , whereas gains in medication adherence occur later in the intervention . although these findings bear replication , among dd patients it may take longer for the behavioral contingencies that support medication taking to emerge than for diet and exercise . furthermore , those in caps displayed significantly greater improvements in medication adherence than those in the other two groups , underscoring the important contribution of distress - focused interventions for highly distressed patients . a somewhat surprising finding is that significant reductions in dds , rd , and eb occur without a significant overall treatment group main effect , suggesting that the pattern of change in dd over time for all three groups is similar . this finding provides evidence that leap ahead , a minimal general health and diabetes education intervention ( 18 ) , is for many patients as effective in reducing distress as casm and caps . taking about the same time as casm and caps , leap ahead did not require , suggest , or encourage patients to change behavior ; its goal was only to provide attention and modest health - related information delivery . excluding initially highly distressed patients , for whom more distressed  focused interventions may be necessary , these findings suggest that most distressed patients are highly responsive to clinical staff attention , concern , and support both with and without the structure of formal programs to change behavior or enhance dd - related problem solving . reducing distress , therefore , may have less to do with providing patients with programs of action and behavioral change and more to do with health care professionals listening to , understanding , acknowledging , and normalizing dd so that patients internal resources can become freer of internal distress  related constraints ( 1,14,15,39 ) . thus , programs to reduce dd may be relatively easy to implement and disseminate and require less skilled staff to administer , thus lowering potential costs . this study had several strengths : a randomized comparative design ; a validated , pragmatic , and low - cost web - based intervention ; delivery by nonprofessional staff ; high program representativeness and reach ( 40 ) ; and use of a large community sample . attrition from baseline to 12 months in a highly distressed sample was moderate ( 18% ) , was not differential among groups , and did not affect outcomes . it may be that focused interventions to reduce dd may be most efficacious for many patients . mean baseline hba1c was low ( 7.4% ) , making improvement as a result of intervention relatively difficult to demonstrate . in conclusion , dd is highly prevalent among patients with type 2 diabetes and is linked with poor disease management and glycemic control , independent of clinical depression . this investigation showed that dd is highly responsive to intervention and that although interventions that improve self - management can also reduce distress , distress - specific interventions need to be delivered for patients with initially high levels of dd . greater attention to dd within the context of self - management improvement programs and general clinical care is warranted .
objectiveto compare three interventions to reduce diabetes distress ( dd ) and improve self - management among non  clinically depressed adults with type 2 diabetes mellitus ( t2dm).research design and methodsin redeem , 392 adults with t2 dm and dd were randomized to computer - assisted self - management ( casm ) , casm plus dd - specific problem solving ( caps ) , or a computer - administered minimal supportive intervention . 
 primary outcomes were diabetes distress scale ( dds ) total , the emotional burden ( eb ) and regimen distress ( rd ) dds subscales , and diet , exercise , and medication adherence.resultssignificant and clinically meaningful reductions in dd ( dds , eb , and rd ) and self - management behaviors occurred in all three conditions ( p < 0.001 ) , with no significant between - group differences . 
 there was , however , a significant group  baseline distress interaction ( p < 0.02 ) , in which patients with high baseline rd in the caps condition displayed significantly larger rd reductions than those in the other two conditions . 
 rd generated the most distress and displayed the greatest distress reduction as a result of intervention . 
 the pace of dd reduction varied by patient age : older patients demonstrated significant reductions in dd early in the intervention , whereas younger adults displayed similar reductions later . 
 reductions in dd were accompanied by significant improvements in healthy eating , physical activity , and medication adherence , although not by change in hba1c.conclusionsdd is malleable and highly responsive to intervention . 
 interventions that enhance self - management also reduce dd significantly , but dd - specific interventions may be necessary for patients with high initial levels of dd . future research should identify the minimal , most cost - effective interventions to reduce dd and improve self - management .