Diabetes distress levels and the prevalence of elevated diabetes distress were considerably lower in the participants treated in primary care ( mean ( SD ) total diabetes distress score 8 ( 11 ) ; 4 % of participants with a Problem Areas In Diabetes score 40 ) than in secondary care ( mean ( SD ) total diabetes distress score 23 ( 21 ) ; 19 % of participants with a Problem Areas In Diabetes score 40 , P < 0.001 ) .