Abstract
Background
Psychological distress, including stress and depressive symptoms, is common among people with diabetes and may negatively influence self-management and clinical outcomes in primary care settings.
Objective
To assess and compare levels of perceived stress and depression among patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM).
Methods
This cross-sectional study included 297 patients with diabetes recruited using convenience sampling from eight primary care centers in Prishtina, Kosovo, between March 2025 and August 2025. Perceived stress was measured using the Perceived Stress Scale (PSS), while depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9). Demographic characteristics and selected clinical parameters, including waist circumference and systolic and diastolic blood pressure, were obtained from medical records. Categorical and continuous variables were analyzed using chi-square and Mann–Whitney U tests, with Cramér’s V measuring categorical effect size. Statistical significance was set at p < 0.05.
Results
Patients with type 1 diabetes mellitus (T1DM) were significantly younger than patients with type 2 diabetes mellitus (T2DM). Exploratory item-level analysis of perceived stress did not demonstrate consistent differences between the groups; however, interpretation of stress-related findings should be approached cautiously due to the low internal consistency of the PSS in the present sample. Depressive symptom severity differed significantly between groups (p = 0.005, Cramér’s V = 0.224).
Conclusion
Significant differences were observed in depressive symptom severity between patients with T1DM and T2DM, whereas interpretation of perceived stress findings remains limited. Although these findings support the importance of psychological assessment in diabetes care, they should be interpreted cautiously given the cross-sectional design and methodological limitations of the study. Healthcare professionals, including physicians and nurses, should routinely screen for depression in diabetes care and provide appropriate follow-up or referral based on symptom severity.
Keywords: diabetes mellitus, type 1; diabetes mellitus, type 2; stress, psychological; depression; patient health questionnaire-9; perceived stress scale; cross-sectional studies; primary health care
Background
Diabetes mellitus is a major public health concern that substantially affects patients’ quality of life and places a growing burden on health care systems worldwide (Inga-Britt & Kerstin, 2019). As a complex and chronic condition, diabetes requires lifelong management and continuous medical care, extending beyond glycemic control to include multifactorial risk-reduction strategies and sustained patient self-management education (American Diabetes Association [ADA], 2018). Effective self-care and ongoing support are essential to prevent acute complications and reduce long-term adverse outcomes. In addition to its physical consequences, diabetes has a considerable psychological impact. Common psychological conditions among people with diabetes include depression, anxiety, and stress, which may further complicate disease management and overall well-being (Tan et al., 2015).
Depression, in particular, represents a major global health challenge and has been identified by the World Health Organization as a leading contributor to disability-adjusted life years lost worldwide (World Health Assembly, 2012). Evidence suggests that stress levels are also high among individuals with diabetes, with some studies reporting a higher prevalence among women than men (Aekplakorn et al., 2018).
The co-existence of diabetes and depression has important clinical implications. A meta-analysis has shown that comorbid depression is associated with poorer adherence to diabetes self-management behaviors, including diet, medication use, and physical activity (Gonzalez et al., 2008). Numerous studies have reported a high prevalence of depressive symptoms among individuals with diabetes, although the reported rates vary widely across regions and populations (Alhunayni et al., 2020). This variability highlights the influence of demographic, clinical, and contextual factors on psychological outcomes in people living with diabetes.
In Kosovo and other regions, diabetes and its associated comorbidities represent a significant public health burden. Population-based data from Kosovo have demonstrated a notable prevalence of diabetes mellitus alongside hypertension, conditions that frequently coexist and further impair quality of life (Sopjani & Elezi, 2021). Studies from different geographic settings have documented substantial variation in the prevalence of depression among patients with diabetes, underscoring the need for context-specific evidence (Alateeq, 2020; Albasheer et al., 2018; Aljohani et al., 2021; Alzahrani et al., 2019). These findings suggest that the psychological burden associated with diabetes may also represent an important but underexplored public health concern within the Kosovo primary healthcare context.
Previous research suggests that the prevalence of depression may be up to three times higher in individuals with type 1 diabetes and similarly elevated in those with type 2 diabetes compared with the general population (Alateeq, 2020; Holt, 2025). In addition, previous studies have documented substantial levels of stress and anxiety among patients with both type 1 and type 2 diabetes mellitus (Grigsby et al., 2002). However, despite growing evidence regarding psychological distress among individuals with diabetes, comparative data examining differences in perceived stress and depressive symptoms between patients with type 1 and type 2 diabetes mellitus in primary care settings remain limited, particularly in low- and middle-income countries such as Kosovo. Furthermore, few studies have simultaneously explored both perceived stress and depressive symptoms within routine primary healthcare contexts. Addressing this gap may contribute to a better understanding of the psychological burden associated with different types of diabetes and support more integrated approaches to diabetes care.
Based on previous literature suggesting differences in psychological burden between diabetes types, it was expected that patients with type 1 and type 2 diabetes mellitus would demonstrate differences in levels of perceived stress and depressive symptoms.
Methods
Study Design
This study employed a cross-sectional design to examine and compare levels of perceived stress and depression among patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM).
Setting and Participants
The study was conducted among patients with type 1 and type 2 diabetes mellitus attending primary care centers in Prishtina, Kosovo, between March 2025 and August 2025. Participants were recruited using a convenience sampling method. A convenience sampling approach was considered appropriate given the exploratory nature of the study and the practical constraints related to participant recruitment within primary healthcare settings. The inclusion criteria were: a diagnosis of type 1 or type 2 diabetes mellitus for at least one year, ability to communicate in Albanian or English, no history of malignancy, and absence of any acute illness that could affect psychological well-being at the time of data collection. Patients were excluded if they had severe acute or unstable medical conditions that could significantly affect psychological well-being or participation in the study.
A total of 297 eligible participants from eight primary care centers who met the inclusion criteria and agreed to participate were included in the final analyses. No formal sample size calculation was performed because the study employed an exploratory cross-sectional design and included all eligible participants available during the data collection period.
Data Collection Procedure
Potential participants who met the inclusion criteria were identified by staff nurses at the primary care centers and subsequently introduced to the researcher. The researchers provided detailed information about the study objectives, procedures, and potential benefits using a participant information sheet. Written informed consent was obtained from all participants prior to enrollment. Data were collected using structured questionnaires.
Instruments/Questionnaires
The primary outcomes of the study were levels of perceived stress and depression among patients with T1DM and T2DM. Data were collected using structured questionnaires that gathered sociodemographic information and health-related characteristics of the participants. Waist circumference was interpreted according to standard clinical cutoff values indicating increased cardiometabolic risk (>102 cm for men and >88 cm for women). Selected clinical and laboratory parameters, including erythrocyte sedimentation rate (ESR) and hematocrit levels, were obtained from medical records to provide additional clinical context regarding the general health status of the participants.
Perceived Stress Scale (PSS). Perceived stress was assessed using the 10-item Perceived Stress Scale (PSS), developed by Cohen et al. (1983), which measures the degree to which individuals perceive situations in their lives as stressful during the previous month. The scale evaluates feelings of unpredictability, lack of control, and overload related to daily experiences. Responses are rated on a 5-point Likert scale ranging from 0 (never) to 4 (very often), yielding a total score between 0 and 40, with higher scores indicating greater perceived stress. Scores of 0–13 indicate low perceived stress, 14–26 indicate moderate perceived stress, and 27–40 indicate high perceived stress (Cohen et al., 1983). The internal consistency of the PSS was assessed using Cronbach’s alpha coefficient (α = 0.049). Therefore, PSS findings are presented and interpreted at the item level, and total scale scores were not calculated. Because total PSS scores were not calculated, these severity cutoffs were not applied in the present study.
Patient Health Questionnaire-9 (PHQ-9). Depressive symptoms were measured using the PHQ-9, a nine-item instrument derived from the PRIME-MD diagnostic tool for common mental disorders. It assesses the frequency of nine depressive symptoms based on DSM-IV criteria over the preceding two weeks. Each item is scored on a 4-point scale from 0 (not at all) to 3 (nearly every day), resulting in a total score ranging from 0 to 27. A diagnosis of major depressive disorder is suggested when five or more depressive symptoms are present for more than half of the days during the past two weeks, with at least one symptom being depressed mood or anhedonia. Other depressive disorders are suggested when two to four symptoms meet these criteria. The ninth item, assessing thoughts of self-harm or death, is considered clinically significant if endorsed at any frequency. PHQ-9 scores indicate minimal depression (0–4), mild (5–9), moderate (10–14), moderately severe (15–19), or severe (20+) (Kroenke et al., 2001). The PHQ-9 had a Cronbach’s α of 0.639 in this sample.
The PHQ-9 and PSS questionnaires were administered in the Albanian language during face-to-face interviews. The questionnaires were translated from English into Albanian by a bilingual translator familiar with health-related terminology. The Albanian versions were independently back-translated into English by a second bilingual translator who was blinded to the original wording. The original and back-translated versions were compared, and discrepancies were reviewed and resolved by consensus to ensure semantic and conceptual equivalence. The Albanian versions used in this study had not undergone formal psychometric validation in the Kosovo population.
Regarding the instrument use and permission, the PHQ-9 was used for non-commercial academic research in accordance with the applicable terms of use associated with the instrument and its copyright holder, Pfizer Inc. Under these terms, no separate written permission was required for the present research use. The Perceived Stress Scale (PSS-10) was used for non-commercial academic research in accordance with the applicable conditions of use, and the original source of the instrument was appropriately cited.
Data Analysis
Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 26.0 (IBM Corp., Armonk, NY, USA), licensed by the University of Prishtina. The internal consistency of the measurement instruments was assessed using Cronbach’s alpha coefficient. Descriptive statistics were summarized as means and standard deviations, medians and interquartile ranges (IQRs) for continuous variables, and as frequencies and percentages for categorical variables. Differences between patients with T1DM and type 2 diabetes mellitus T2DM were examined using the chi-square test for categorical variables and the Mann–Whitney U test for continuous variables. For categorical comparisons, Cramér’s V was calculated and reported as an effect-size measure. A p-value < 0.05 was considered statistically significant.
The distribution of continuous variables was assessed prior to analyses. Because several variables did not demonstrate normal distribution, nonparametric analyses (Mann–Whitney U test) were applied for between-group comparisons of continuous variables. Assumptions for multivariable linear regression analysis, including normality of residuals, homoscedasticity, multicollinearity, and independence of residuals, were evaluated and considered acceptable.
Given the exploratory and comparative nature of the study, analyses were primarily conducted using bivariate statistical tests. Due to the substantial baseline differences between participants with type 1 and type 2 diabetes mellitus, an additional multivariable linear regression analysis was conducted to explore the potential influence of confounding variables such as age, sex, and duration of diabetes on depressive symptom scores. All nine PHQ-9 items were completed by all 297 participants. Therefore, PHQ-9 total scores and depression-severity categories were calculated using complete responses to all nine items, with no imputation of missing values. No participants were excluded due to missing PHQ-9 data. All PSS items were also complete for all participants, and no imputation was required for the PSS item-level analyses. Item-level analyses were conducted to explore differences in specific depressive symptoms between groups, whereas categorical PHQ-9 severity analyses were used to facilitate clinically meaningful interpretation of depressive symptom burden.
Ethical Considerations
The study protocol was reviewed and approved by the Scientific Ethics Committee of the Faculty of Medicine, University of Prishtina, Kosovo (approval No. 124/1; January 22, 2025). All participants received detailed information about the study and provided written informed consent prior to participation. Participation was voluntary, with confidentiality and anonymity were ensured throughout the study. Participants who expressed significant psychological distress or endorsed thoughts related to self-harm during data collection were advised to seek further evaluation and support from healthcare professionals at the respective primary healthcare centers.
Results
A total of 297 patients with type 1 and type 2 diabetes mellitus were included in the study. Patients with T1DM were significantly younger than those with T2DM (p < 0.001). Selected demographic, anthropometric, clinical, and treatment-related characteristics of the participants are summarized in Table 1 and Table 2.
Table 1.
Demographic and clinical characteristics of patients with type 1 and type 2 diabetes
| Variable | Total (N = 297) | T1DM (n = 87) | T2DM (n = 210) | p |
|---|---|---|---|---|
| Demographic characteristics | ||||
| Age (years), mean ± SD | 55.7 ± 16.7 | 38.4 ± 16.1 | 62.9 ± 10.6 | < 0.001 |
| Age (years), median (IQR) | 59 (22) | 34 (18) | 64 (12) | |
| Sex, n (%) | 0.208 | |||
| Female | 120 (40.4) | 40 (46.0) | 80 (38.1) | |
| Male | 177 (59.6) | 47 (54.0) | 130 (61.9) | |
| Anthropometric characteristics | ||||
| Body weight (kg), mean ± SD | 77.0 ± 16.4 | 67.9 ± 14.5 | 80.8 ± 15.7 | < 0.001 |
| Waist circumference (cm), mean ± SD | 99.5 ± 17.3 | 89.8 ± 13.2 | 103.6 ± 17.2 | < 0.001 |
| Lifestyle and comorbidity characteristics | ||||
| Smoking status, n (%) | 0.960 | |||
| Yes | 62 (20.9) | 18 (20.7) | 44 (21.0) | |
| No | 235 (79.1) | 69 (79.3) | 166 (79.0) | |
| Chronic obstructive pulmonary disease, n (%) | 0.162 | |||
| Yes | 28 (9.4) | 5 (5.7) | 23 (11.0) | |
| No | 269 (90.6) | 82 (94.3) | 187 (89.0) | |
| Diabetes-related clinical characteristics | ||||
| Duration of diabetes (months), mean ± SD | 134.3 ± 97.6 | 125.4 ± 109.6 | 138.0 ± 92.3 | 0.195 |
| Treatment-related characteristics | ||||
| Insulin therapy duration (months), mean ± SD | 55.1 ± 79.1 | 112.0 ± 105.1 | 31.5 ± 49.1 | < 0.001 |
| Duration of oral antidiabetic therapy (months), mean ± SD | 97.5 ± 97.1 | 19.4 ± 55.2 | 129.8 ± 92.3 | < 0.001 |
| Oral antidiabetic therapy use, n (%) | < 0.001 | |||
| Yes | 228 (76.8) | 26 (29.9) | 202 (96.2) | |
| No | 69 (23.2) | 61 (70.1) | 8 (3.8) | |
Note: Continuous variables were compared using the Mann–Whitney U test, and categorical variables were compared using the chi-square test. Cramér’s V was used as an effect-size measure for categorical comparisons. Cramér’s V values were 0.073 for sex, 0.003 for smoking status, 0.081 for chronic obstructive pulmonary disease, and 0.715 for oral antidiabetic therapy use. p values are two-tailed. Duration of oral antidiabetic therapy is reported among users only (T1DM n = 26; T2DM n = 202); non-users were excluded from this calculation.
Table 2.
Clinical and laboratory characteristics of patients with type 1 and type 2 diabetes mellitus
| Variable | Total (N = 297) | T1DM (n = 87) | T2DM (n = 210) | p |
|---|---|---|---|---|
| Liver function | ||||
| Alanine aminotransferase (ALT), mean ± SD | 23.1 ± 17.6 | 20.4 ± 13.3 | 24.2 ± 19.0 | 0.049 |
| Aspartate aminotransferase (AST), mean ± SD | 23.8 ± 16.4 | 24.5 ± 14.8 | 23.5 ± 17.1 | 0.671 |
| Hematological parameters | ||||
| Erythrocyte sedimentation rate (ESR, mm/h), mean ± SD | 28.0 ± 22.8 | 22.1 ± 16.8 | 30.5 ± 24.5 | 0.027 |
| White blood cell count (×103/µL), mean ± SD | 8.7 ± 5.3 | 9.1 ± 3.7 | 8.5 ± 5.8 | 0.030 |
| Hematocrit (%), mean ± SD | 41.7 ± 6.9 | 43.7 ± 8.6 | 40.9 ± 5.8 | 0.002 |
| Platelet count (×103/µL), mean ± SD | 235.7 ± 89.1 | 227.3 ± 98.8 | 239.2 ± 84.8 | 0.482 |
| Glycemic control | ||||
| Fasting plasma glucose (mmol/L), mean ± SD | 12.1 ± 4.8 | 12.9 ± 6.0 | 11.7 ± 4.2 | 0.517 |
| Postprandial glucose—lunch (mmol/L), mean ± SD | 13.1 ± 5.1 | 13.2 ± 5.4 | 13.1 ± 5.0 | 0.898 |
| Postprandial glucose—dinner (mmol/L), mean ± SD | 10.9 ± 5.4 | 11.0 ± 5.2 | 10.9 ± 5.5 | 0.908 |
| Blood pressure | ||||
| Systolic blood pressure (mmHg), mean ± SD | 132.9 ± 20.4 | 123.9 ± 18.1 | 136.7 ± 20.2 | < 0.001 |
| Diastolic blood pressure (mmHg), mean ± SD | 80.0 ± 14.1 | 76.9 ± 10.7 | 81.3 ± 15.1 | < 0.001 |
| Renal function | ||||
| Urea (mmol/L), mean ± SD | 8.8 ± 5.1 | 7.4 ± 5.3 | 9.4 ± 4.8 | < 0.001 |
| Creatinine (µmol/L), mean ± SD | 108.1 ± 88.5 | 101.5 ± 77.7 | 110.9 ± 92.7 | 0.004 |
Note: Continuous variables were compared between groups using the Mann–Whitney U test. p values are two-tailed.
A statistically significant association was observed for oral antidiabetic therapy use between patients with type 1 and type 2 diabetes mellitus (χ2(1) = 151, p < 0.001), with a strong association (Cramér’s V = 0.715). Patients with T2DM demonstrated significantly higher alanine aminotransferase, erythrocyte sedimentation rate, systolic blood pressure, diastolic blood pressure, urea, and creatinine levels compared with patients with T1DM, whereas white blood cell count and hematocrit levels were significantly higher among patients with T1DM. No statistically significant between-group differences were observed for AST, platelet count, fasting plasma glucose, or postprandial glucose levels.
Overall, no statistically significant differences were observed between participants with type 1 and type 2 diabetes across most items of the Perceived Stress Scale (PSS). However, a significant between-group difference was identified for the item assessing feelings of nervousness and stress (p = 0.008, Cramér’s V = 0.217), with “very often” responses more frequently reported among participants with T1DM than among those with T2DM (49.4% vs 32.9%) (Table 3).
Table 3.
Item-level responses to the perceived stress scale among participants with type 1 and type 2 diabetes
| PSS item and response category | T1DM (n = 87), n (%) | T2DM (n = 210), n (%) | p | Cramér’s V |
|---|---|---|---|---|
| S1. In the last month, how often have you been upset because of something that happened unexpectedly? | 0.273 | 0.115 | ||
| Almost never | 3 (3.4) | 7 (3.3) | ||
| Sometimes | 22 (25.3) | 65 (31.0) | ||
| Often | 51 (58.6) | 98 (46.7) | ||
| Very often | 11 (12.6) | 40 (19.0) | ||
| S2. In the last month, how often have you felt that you were unable to control the important things in your life? | 0.349 | 0.122 | ||
| Never | 8 (9.2) | 9 (4.3) | ||
| Almost never | 12 (13.8) | 23 (11.0) | ||
| Sometimes | 33 (37.9) | 92 (43.8) | ||
| Often | 32 (36.8) | 76 (36.2) | ||
| Very often | 2 (2.3) | 10 (4.8) | ||
| S3. In the last month, how often have you felt nervous and stressed? | 0.008 | 0.217 | ||
| Never | 0 (0.0) | 2 (1.0) | ||
| Almost never | 5 (5.7) | 3 (1.4) | ||
| Sometimes | 16 (18.4) | 62 (29.5) | ||
| Often | 23 (26.4) | 74 (35.2) | ||
| Very often | 43 (49.4) | 69 (32.9) | ||
| S4. In the last month, how often have you felt confident about your ability to handle your personal problems? | 0.703 | 0.086 | ||
| Very often | 2 (2.3) | 8 (3.8) | ||
| Often | 12 (13.8) | 31 (14.8) | ||
| Sometimes | 55 (63.2) | 116 (55.2) | ||
| Almost never | 14 (16.1) | 46 (21.9) | ||
| Never | 4 (4.6) | 9 (4.3) | ||
| S5. In the last month, how often have you felt that things were going your way? | 0.253 | 0.134 | ||
| Very often | 5 (5.7) | 11 (5.2) | ||
| Often | 24 (27.6) | 37 (17.6) | ||
| Sometimes | 40 (46.0) | 124 (59.0) | ||
| Almost never | 16 (18.4) | 32 (15.2) | ||
| Never | 2 (2.3) | 6 (2.9) | ||
| S6. In the last month, how often have you found that you could not cope with all the things that you had to do? | 0.065 | 0.172 | ||
| Never | 2 (2.3) | 2 (1.0) | ||
| Almost never | 11 (12.6) | 13 (6.2) | ||
| Sometimes | 28 (32.2) | 102 (48.6) | ||
| Often | 39 (44.8) | 77 (36.7) | ||
| Very often | 7 (8.0) | 16 (7.6) | ||
| S7. In the last month, how often have you been able to control irritations in your life? | 0.568 | 0.099 | ||
| Very often | 4 (4.6) | 5 (2.4) | ||
| Often | 10 (11.5) | 26 (12.4) | ||
| Sometimes | 57 (65.5) | 148 (70.5) | ||
| Almost never | 16 (18.4) | 29 (13.8) | ||
| Never | 0 (0.0) | 2 (1.0) | ||
| S8. In the last month, how often have you felt that you were on top of things? | 0.459 | 0.110 | ||
| Very often | 2 (2.3) | 5 (2.4) | ||
| Often | 15 (17.2) | 23 (11.0) | ||
| Sometimes | 52 (59.8) | 139 (66.2) | ||
| Almost never | 18 (20.7) | 40 (19.0) | ||
| Never | 0 (0.0) | 3 (1.4) | ||
| S9. In the last month, how often have you been angered because of things that were outside of your control? | 0.120 | 0.157 | ||
| Never | 0 (0.0) | 5 (2.4) | ||
| Almost never | 5 (5.7) | 4 (1.9) | ||
| Sometimes | 29 (33.3) | 74 (35.2) | ||
| Often | 49 (56.3) | 107 (51.0) | ||
| Very often | 4 (4.6) | 20 (9.5) | ||
| S10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them? | 0.706 | 0.085 | ||
| Never | 0 (0.0) | 2 (1.0) | ||
| Almost never | 2 (2.3) | 8 (3.8) | ||
| Sometimes | 28 (32.2) | 55 (26.2) | ||
| Often | 38 (43.7) | 98 (46.7) | ||
| Very often | 19 (21.8) | 47 (22.4) |
Note: p values were calculated using the chi-square test. Cramér’s V was calculated as an effect-size measure for categorical comparisons. Some comparisons included expected cell counts below 5; therefore, these results should be interpreted cautiously.
Item-level analysis of the PHQ-9 showed statistically significant differences between participants with type 1 and type 2 diabetes for the item assessing sleep difficulties (item 3, p < 0.001, Cramér’s V = 0.265) and the item assessing negative self-perception (item 6, p = 0.003, Cramér’s V = 0.215). No statistically significant between-group differences were observed for the remaining PHQ-9 items (Table 4).
Table 4.
Item-level responses to the Patient Health Questionnaire-9 among participants with type 1 and type 2 diabetes
| PHQ-9 item and response category | Total (N = 297), n (%) | T1DM (n = 87), n (%) | T2DM (n = 210), n (%) | p | Cramér’s V |
|---|---|---|---|---|---|
| 1. Little interest or pleasure in doing things? | 0.516 | 0.088 | |||
| Not at all | 56 (18.9) | 19 (21.8) | 37 (17.6) | ||
| Several days | 209 (70.4) | 60 (69.0) | 149 (71.0) | ||
| More than half the days | 14 (4.7) | 2 (2.3) | 12 (5.7) | ||
| Nearly every day | 18 (6.1) | 6 (6.9) | 12 (5.7) | ||
| 2. Feeling down, depressed, or hopeless? | 0.641 | 0.075 | |||
| Not at all | 38 (12.8) | 13 (14.9) | 25 (11.9) | ||
| Several days | 133 (44.8) | 35 (40.2) | 98 (46.7) | ||
| More than half the days | 64 (21.5) | 18 (20.7) | 46 (21.9) | ||
| Nearly every day | 62 (20.9) | 21 (24.1) | 41 (19.5) | ||
| 3. Trouble falling or staying asleep, or sleeping too much? | < 0.001 | 0.265 | |||
| Not at all | 61 (20.5) | 22 (25.3) | 39 (18.6) | ||
| Several days | 75 (25.3) | 10 (11.5) | 65 (31.0) | ||
| More than half the days | 53 (17.8) | 26 (29.9) | 27 (12.9) | ||
| Nearly every day | 108 (36.4) | 29 (33.3) | 79 (37.6) | ||
| 4. Feeling tired or having little energy? | 0.417 | 0.098 | |||
| Not at all | 15 (5.1) | 2 (2.3) | 13 (6.2) | ||
| Several days | 52 (17.5) | 18 (20.7) | 34 (16.2) | ||
| More than half the days | 64 (21.5) | 17 (19.5) | 47 (22.4) | ||
| Nearly every day | 166 (55.9) | 50 (57.5) | 116 (55.2) | ||
| 5. Poor appetite or overeating? | 0.353 | 0.105 | |||
| Not at all | 33 (11.1) | 9 (10.3) | 24 (11.4) | ||
| Several days | 117 (39.4) | 35 (40.2) | 82 (39.0) | ||
| More than half the days | 61 (20.5) | 13 (14.9) | 48 (22.9) | ||
| Nearly every day | 86 (29.0) | 30 (34.5) | 56 (26.7) | ||
| 6. Feeling bad about yourself—or that you’re a failure or have let yourself or your family down? | 0.003 | 0.215 | |||
| Not at all | 72 (24.2) | 30 (34.5) | 42 (20.0) | ||
| Several days | 135 (45.5) | 30 (34.5) | 105 (50.0) | ||
| More than half the days | 54 (18.2) | 21 (24.1) | 33 (15.7) | ||
| Nearly every day | 36 (12.1) | 6 (6.9) | 30 (14.3) | ||
| 7. Trouble concentrating on things, such as reading the newspaper or watching television? | 0.261 | 0.116 | |||
| Not at all | 80 (26.9) | 25 (28.7) | 55 (26.2) | ||
| Several days | 124 (41.8) | 29 (33.3) | 95 (45.2) | ||
| More than half the days | 52 (17.5) | 18 (20.7) | 34 (16.2) | ||
| Nearly every day | 41 (13.8) | 15 (17.2) | 26 (12.4) | ||
| 8. Moving or speaking so slowly that others could have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual? | 0.618 | 0.078 | |||
| Not at all | 48 (16.2) | 17 (19.5) | 31 (14.8) | ||
| Several days | 172 (57.9) | 46 (52.9) | 126 (60.0) | ||
| More than half the days | 48 (16.2) | 14 (16.1) | 34 (16.2) | ||
| Nearly every day | 29 (9.8) | 10 (11.5) | 19 (9.0) | ||
| 9. Thoughts that you would be better off dead or of hurting yourself in some way? | 0.082 | 0.150 | |||
| Not at all | 152 (51.2) | 53 (60.9) | 99 (47.1) | ||
| Several days | 98 (33.0) | 26 (29.9) | 72 (34.3) | ||
| More than half the days | 22 (7.4) | 5 (5.7) | 17 (8.1) | ||
| Nearly every day | 25 (8.4) | 3 (3.4) | 22 (10.5) |
Note: p values were calculated using the chi-square test. Cramér’s V was calculated as an effect-size measure for categorical comparisons. Some comparisons included expected cell counts below 5; therefore, these results should be interpreted cautiously.
The distribution of depression severity levels differed significantly between participants with type 1 and type 2 diabetes (p = 0.005, Cramér’s V = 0.224). Moderate depression was more frequently observed among participants with T2DM (44.3%) than among those with T1DM (23.0%), whereas moderately severe depression was more common among participants with T1DM (39.1%) than among those with T2DM (22.4%) (Table 5).
Table 5.
Differences in depression severity levels (PHQ-9) between participants with type 1 and type 2 diabetes
| PHQ-9 category | Score range | Total (N = 297), n (%) | T1DM (n = 87), n (%) | T2DM (n = 210), n (%) |
|---|---|---|---|---|
| Minimal depression | 0–4 | 12 (4.0) | 4 (4.6) | 8 (3.8) |
| Mild depression | 5–9 | 70 (23.6) | 24 (27.6) | 46 (21.9) |
| Moderate depression | 10–14 | 113 (38.0) | 20 (23.0) | 93 (44.3) |
| Moderately severe depression | 15–19 | 81 (27.3) | 34 (39.1) | 47 (22.4) |
| Severe depression | 20–27 | 21 (7.1) | 5 (5.7) | 16 (7.6) |
Note: p value was calculated using the chi-square test. Cramér’s V was calculated as an effect-size measure for the categorical comparison. p = 0.005; Cramér’s V = 0.224. The PHQ-9 severity comparison included an expected cell count below 5 for minimal depression; this finding should be interpreted cautiously.
A multiple linear regression analysis was performed to assess the independent associations of diabetes type, age, sex, and duration of diabetes with PHQ-9 scores. The overall regression model was not statistically significant, F(4,292) = 1.430, p = 0.224, with an R2 of 0.019 and an adjusted R2 of 0.006, indicating that the model explained approximately 1.9% of the variance in PHQ-9 scores. None of the examined predictors was significantly associated with PHQ-9 scores. Diabetes type was not significantly associated with PHQ-9 scores (B = 0.962, β = 0.075, p = 0.345), nor were age (B = -0.035, β = -0.099, p = 0.225) or sex (B = -1.311, β = -0.110, p = 0.061). Duration of diabetes was also not significantly associated with PHQ-9 scores (B = 0.002, β = 0.037, p = 0.538). Therefore, the regression analysis did not identify any independent predictor of PHQ-9 scores in this model (Table 6).
Table 6.
Multiple linear regression analysis of factors associated with depression (PHQ-9) among patients with diabetes mellitus
| Variable | B | SE | β | t | p | 95 % CI |
|---|---|---|---|---|---|---|
| Diabetes type (T1DM vs. T2DM) | 0.962 | 1.017 | 0.075 | 0.946 | 0.345 | −1.040 to 2.963 |
| Age | −0.035 | 0.029 | −0.099 | −1.216 | 0.225 | −0.091 to 0.021 |
| Sex | −1.311 | 0.697 | −0.110 | −1.881 | 0.061 | −2.682 to 0.060 |
| Duration of diabetes | 0.002 | 0.004 | 0.037 | 0.616 | 0.538 | −0.005 to 0.009 |
Note. B = unstandardized regression coefficient; SE = standard error; β = standardized regression coefficient; CI = confidence interval; Diabetes type was coded as 0 = T1DM (reference category) and 1 = T2DM. Sex was coded as 0 = male and 1 = female. Predictors were entered simultaneously. Model statistics: R = 0.139, R2 = 0.019, adjusted R2 = 0.006, F(4, 292) = 1.430, p = 0.224. Durbin–Watson = 1.859. VIF values ranged from 1.017 to 1.971, and tolerance values ranged from 0.507 to 0.983, indicating no substantial multicollinearity. Inspection of the residual histogram and normal P–P plot indicated that residuals were approximately normally distributed. Standardized residuals ranged from -2.602 to 2.535, and Cook’s distance ranged from 0.000 to 0.036, indicating no substantial influential observations. The model explained 1.9% of the variance in PHQ-9 scores (adjusted R2 = 0.006).
Discussion
The present study examined perceived stress and depressive symptoms among patients with type 1 and type 2 diabetes mellitus, with the aim of identifying potential differences between the two groups. The low internal consistency observed for the Perceived Stress Scale in this sample may reflect methodological or contextual factors influencing participants’ responses to stress-related items.
Regarding perceived stress, item-level analysis of the Perceived Stress Scale (PSS) revealed no statistically significant differences between patients with type 1 and type 2 diabetes for most items, with a significant difference observed only for the item assessing feelings of nervousness and stress. Therefore, stress-related findings in this study should be considered exploratory rather than confirmatory and interpreted within the context of substantial measurement limitations. Although item-level comparisons were explored descriptively, the instrument lacked adequate reliability to support strong conclusions about perceived stress differences between patients with type 1 and type 2 diabetes mellitus.
Previous studies conducted in different settings have reported variable levels of stress among people with diabetes. Research from India and China has documented elevated stress levels among patients with type 2 diabetes (Sendhilkumar et al., 2017; Siddharthan et al., 2021; Zhao et al., 2018), whereas studies from Malaysia and Croatia have reported lower prevalence estimates, reflecting the use of different assessment tools and scoring methods (Bralić Lang et al., 2015; Kaur et al., 2013; Zhao et al., 2018). More recent evidence highlights that psychological stress in diabetes is often captured by the broader concept of diabetes distress, which reflects the emotional burden associated with long-term disease management rather than clinical stress alone (Reimer et al., 2017; Roy & Lloyd, 2012). This distinction may partly explain inconsistencies in stress-related findings across studies.
In our study, patients with type 2 diabetes had significantly higher waist circumference compared with those with type 1 diabetes. Although no direct association analyses were conducted in the present study, previous research has reported potential relationships between psychosocial stress and body mass index across diverse populations, including individuals with diabetes (Harding et al., 2014; Vasanth et al., 2017). Elevated body mass index represents an important clinical concern, as it has been associated with increased cardiovascular morbidity, mortality, and diabetic nephropathy among patients with type 2 diabetes (Eeg-Olofsson et al., 2009; Khalangot et al., 2009). These findings emphasize the need for integrated clinical and psychosocial approaches in diabetes management.
Depressive symptoms assessed using the Patient Health Questionnaire-9 (PHQ-9) differed significantly between patients with type 1 and type 2 diabetes. In this study, moderate depressive symptoms were more common among patients with type 2 diabetes, whereas moderately severe depressive symptoms were more frequently observed among patients with type 1 diabetes. These findings highlight the heterogeneous psychological burden associated with different diabetes types and underscore the importance of distinguishing between patterns of depressive symptom severity.
The observed differences in depressive symptom severity between the study groups may also have been influenced by differences in demographic and clinical characteristics, particularly age, which differed substantially between participants with type 1 and type 2 diabetes mellitus. Consequently, some between-group differences observed in the present study may partially reflect demographic heterogeneity rather than differences attributable solely to diabetes type. These findings suggest that psychological burden in diabetes may not be uniformly distributed across diabetes types and may also reflect differences in long-term disease experience, treatment demands, and demographic characteristics between the study groups. Although several between-group differences reached statistical significance, the clinical relevance of these findings should be interpreted cautiously given the exploratory nature of the study and the potential influence of demographic and methodological factors.
Depression in diabetes is a well-recognized comorbidity, with evidence suggesting that individuals with diabetes experience nearly twice the prevalence of depressive symptoms compared with the general population (Farooqi et al., 2022). The observed prevalence of depressive symptoms among patients with type 2 diabetes in the present study is consistent with findings from Vietnam and other international settings (Tran et al., 2021). Longitudinal research indicates that depressive symptoms in individuals with type 2 diabetes may persist over time, often in conjunction with diabetes-related distress, thereby increasing the risk of sustained psychological morbidity (Khaledi et al., 2019; Nanayakkara et al., 2018; Reimer et al., 2017; Zhang et al., 2015).
Across countries and studies, the reported prevalence of depression among patients with type 2 diabetes varies widely. Large observational studies from China and Australia have reported prevalence rates ranging from 5.7% to 29%, depending on the population studied and the diagnostic criteria applied (Nanayakkara et al., 2018; Zhang et al., 2015). A comprehensive meta-analysis including more than 80 million individuals with diabetes worldwide estimated a global prevalence of depression of approximately 28%, with higher rates reported in Asia and Australia compared with Europe and Africa (Khaledi et al., 2019). This variability is likely influenced by differences in assessment instruments, such as the Beck Depression Inventory, PHQ-9, CESD, HADS, and DASS-21, as well as the use of different cutoff scores to define depression (Farooqi et al., 2022; Fisher et al., 2014; Khaledi et al., 2019; Reimer et al., 2017; Roy & Lloyd, 2012).
Overall, these findings reinforce the importance of routine screening for depressive symptoms in patients with both type 1 and type 2 diabetes. International guidelines increasingly emphasize the integration of mental health assessment into routine diabetes care to facilitate early identification of psychological distress and timely intervention, thereby improving overall disease management and quality of life (Farooqi et al., 2022; Fisher et al., 2014; Roy & Lloyd, 2012; Young-Hyman et al., 2016).
Implications
The study’s findings indicate that depressive symptoms are common among patients with both type 1 and type 2 diabetes mellitus, with moderate depressive symptoms more frequently observed among patients with type 2 diabetes and moderately severe symptoms more common among patients with type 1 diabetes. These results highlight the importance of integrating routine mental health screening into diabetes care, particularly in primary healthcare settings.
Healthcare professionals, including physicians and nurses, play a key role in identifying psychological distress in patients with diabetes. Patient education focusing on the emotional impact of diabetes, diabetes-related distress, and depressive symptoms may enhance patients’ understanding of their condition and support timely help-seeking behavior. Early identification and appropriate referral of patients exhibiting symptoms of diabetes distress or depression may support better recognition of psychological needs and encourage more comprehensive diabetes care in primary healthcare settings.
Limitations of the Study
The study’s findings should be interpreted considering certain limitations. The cross-sectional and correlational design limits the ability to establish causal relationships between diabetes type, perceived stress, and depressive symptoms. Although an additional multivariable regression analysis was conducted to explore the potential influence of confounding variables such as age, sex, and duration of diabetes on depressive symptom scores, the overall explanatory power of the model was limited, and residual confounding cannot be excluded.
The unequal distribution of participants between the T1DM and T2DM groups may also have influenced the statistical power and stability of between-group comparisons. The use of convenience sampling from primary healthcare centers in a single urban setting may substantially limit the generalizability of the findings to the broader diabetic population in Kosovo. Self-reported questionnaires, rather than clinical interviews, may introduce reporting and social desirability biases, invite subjective symptom interpretation, and miss temporal changes in stress and depression. Furthermore, the low internal consistency (Cronbach’s α = 0.049) observed for the Perceived Stress Scale substantially limits the reliability and interpretability of stress-related findings in the present study; therefore, these findings should be interpreted with considerable caution.
Participant identification through primary healthcare staff may have introduced potential gatekeeper bias, as recruitment could have been influenced by staff judgment or participant accessibility. Moreover, multiple item-level comparisons were conducted without formal adjustment for multiple testing; therefore, isolated statistically significant findings may reflect type I error and should be interpreted cautiously.
The absence of formally validated Albanian-language versions of the PSS and PHQ-9 may represent an additional methodological limitation. Despite these limitations, the study provides valuable preliminary data regarding depressive symptoms and perceived stress among patients with type 1 and type 2 diabetes mellitus in primary healthcare settings in Kosovo, a context in which such data remain limited. Future studies employing longitudinal designs and more robust stress assessment tools are warranted. Also, some item-level chi-square analyses included expected cell counts below 5; therefore, these results should be interpreted cautiously.
Conclusion
This study identified differences in depressive symptom severity between patients with type 1 and type 2 diabetes mellitus in primary healthcare settings. Patients with type 2 diabetes more frequently demonstrated moderate depressive symptoms, whereas moderately severe depressive symptoms were more commonly observed among patients with type 1 diabetes. However, stress-related findings should be interpreted cautiously due to important methodological limitations, particularly the extremely low internal consistency observed for the Perceived Stress Scale in the present sample. The findings highlight the considerable psychological burden experienced by patients with diabetes and support the importance of incorporating mental health awareness into routine diabetes care, particularly in primary healthcare settings. Despite the study limitations, this research provides preliminary evidence from a Kosovo context where data regarding psychological aspects of diabetes remain limited. Further longitudinal and methodologically robust studies are warranted to better clarify the relationship between diabetes and psychological distress.
Acknowledgment
The authors would like to thank all participants for their willingness to take part in this study and the healthcare staff at the study sites for their support during data collection.
Funding Statement
Funding None.
Declaration of Conflicting Interest
The authors declare that they have no conflicts of interest.
Author Contribution
EP (Elvana Podvorica) contributed to the conception and design of the study, data collection, data analysis and interpretation, drafted the manuscript, and approved the final version for publication.
EZ (Edmond Zaimi) contributed to the interpretation of findings, statistical evaluation of the study, scientific review of the manuscript, critically revised the manuscript for important intellectual content, and approved the final version for publication.
EPe (Elizana Petrela) contributed to the study design, interpretation of data, critically revised the manuscript for important intellectual content, and approved the final version for publication.
MO (Musa Oruqi) contributed to data analysis and interpretation, critically reviewed the manuscript for intellectual content, supervised the final version, and approved the manuscript for publication.
Author Biography
Elvana Podvorica is an Assistant Professor at the Faculty of Medicine, Department of Nursing and Midwifery, University of Prishtina, Kosovo. Her academic and research interests include nursing education, mental health in chronic disease, diabetes care, and infection prevention and control. She is actively involved in teaching, research, and mentoring nursing students at undergraduate and postgraduate levels.
Edmond Zaimi is an Assistant Professor at the Faculty of Medicine, University of Medicine, Tirana, Albania, and serves as Head of the Internal Medicine Emergency Service at the University Hospital Center “Mother Teresa”, Tirana. His professional and academic interests include emergency medicine, internal medicine, acute clinical care, chronic disease management, and medical research.
Elizana Petrela, PhD, is a Professor in the Department of Public Health, Faculty of Medicine, University of Medicine, Tirana, Albania. Her academic and research interests include public health, epidemiology, biostatistics, health promotion, and statistical methodologies applied to clinical and public health research.
Musa Oruqi, PhD, MD, is a Professor of Surgery in the Department of Nursing at Alma Mater Europaea – Rezonanca College, Prishtina, Kosovo. He is actively involved in clinical practice, nursing education, academic training, and research. His professional and research interests include surgical care, chronic disease management, clinical education, and interdisciplinary healthcare. He serves as the corresponding author of this study.
Data Availability
The datasets generated during and analyzed during the current study are available from the corresponding author upon reasonable request.
Declaration of Use of AI in Scientific Writing
The authors utilized Gemini during the writing process to enhance readability and eliminate grammatical errors. However, they took full responsibility for the content.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated during and analyzed during the current study are available from the corresponding author upon reasonable request.