Coping style and depression influence the healing of diabetic foot ulcers

NewsBot · Jun 28, 2010

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Coping style and depression influence the healing of diabetic foot ulcers: observational and mechanistic evidence
Vedhara et al
Diabetologia Volume 53, Number 8 / August, 2010

Aims/hypothesis
Experimental evidence suggests that the healing of diabetic foot ulcers is affected by psychosocial factors such as distress. We examined this proposal in a prospective study, in which we considered the role of psychological distress and coping style in the healing of diabetic foot ulcers over a 24 week period. We also explored the role of salivary cortisol and matrix metalloproteinases (MMPs) as potential mechanisms.

Methods
For this prospective observational study we recruited 93 (68 men; mean age 60 years) patients with neuropathic or neuroischaemic diabetic foot ulcers from specialist podiatry clinics in secondary care. Clinical and demographic determinants of healing, psychological distress, coping, salivary cortisol and both MMP2 and MMP9 were assessed at baseline. Ulcers were assessed at baseline and at 6, 12 and 24 weeks post-baseline. The primary outcome was ulcer status at 24 weeks, i.e. healed vs not healed.

Results
After controlling for clinical and demographic determinants of healing, ulcer healing at 24 weeks was predicted by confrontation coping, but not by depression or anxiety. Patients with unhealed ulcers exhibited greater confrontation coping (model including depression: OR 0.809, 95% CI 0.704–0.929, p = 0.003; model including anxiety: OR 0.810, 95% CI 0.704–0.930, p = 0.003). However, change in ulcer size over the observation period was associated with depression only (p = 0.04, d = 0.31). Healed ulcers by 24 weeks were also associated with lower evening cortisol, higher precursor MMP2 and a greater cortisol awakening response.

Conclusions/interpretation
Confrontation coping and depression predict ulcer healing. Our preliminary enquiry into biological mechanisms suggests that cortisol and precursor MMP2 may underlie these relationships.
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NewsBot · Sep 5, 2010

Depression predicts first but not recurrent diabetic foot ulcers
J. S. Gonzalez, L. Vileikyte, J. S. Ulbrecht, R. R. Rubin, A. P. Garrow, C. Delgado, P. R. Cavanagh, A. J. M. Boulton and M. Peyrot
Diabetologia Volume 53, Number 10, 2241-2248

Aims/hypothesis
This study examined the relationship between symptoms of depression and the development of diabetic foot ulcers.

Methods
Participants were 333 patients (71% male; mean age 62 years; 73% with type 2 diabetes) with diabetic peripheral neuropathy (DPN), but without peripheral vascular disease (PVD). Severity of DPN and the presence of PVD were assessed by clinical examination. Depression, other diabetes complications and foot self-care were assessed by self-report. Cox regression tested whether depression was an independent predictor of foot ulceration over 18 months, whether this relationship was moderated by foot ulcer history, and whether foot self-care mediated this relationship.

Results
During follow-up, 63 patients developed a foot ulcer. Those with prior foot ulcers had more than four-fold greater risk of subsequent foot ulceration compared with those without a history of foot ulcer. A significant interaction effect showed that depression was significantly related to the development of first but not recurrent foot ulcers. This relationship was independent of biological risk factors. In the final model, each standard deviation increase in depression symptoms was significantly associated with increased risk of developing first foot ulcers (HR 1.68, 95% CI 1.20–2.35), while foot self-care was associated with lower risk (HR 0.61, 95% CI 0.40–0.94). Foot self-care did not mediate the relationship between depression and foot ulceration.

Conclusions/interpretation
These data suggest that depression is associated with increased risk of first foot ulcers in DPN patients and that this relationship is independent of biological risk factors and foot self-care. Interventions that target depression and foot self-care before the development of foot ulcers may maximise the likelihood of successful prevention of foot ulceration.
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syabariyah · Apr 25, 2011

hi,..may I pdf file of coping style?

Lab Guy · Apr 26, 2011

Confrontation coping and depression.

One solution is tell the patient to treat themselves to a vacation or something else they like once their ulcer is healed. This will get their minds on their special treat to themselves as well as a healed foot. The mind connection to the body can never be underestimated, they are indeed intertwined.

Steven

NewsBot · Nov 9, 2011

Five-year follow-up of a cohort of people with their first diabetic foot ulcer: the persistent effect of depression on mortality.
Winkley K, Sallis H, Kariyawasam D, Leelarathna LH, Chalder T, Edmonds ME, Stahl D, Ismail K.
Diabetologia. 2011 Nov 6

AIMS/HYPOTHESIS:
Depressive disorders are associated with mortality within 18 months of presentation of diabetic foot ulcers (DFU). The main aim of this study was to determine whether depressive disorder is still associated with increased mortality in people with their first foot ulcer at 5 years.

METHODS:
This is a 5-year follow-up of a cohort of 253 patients presenting with their first DFU. At baseline, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) 2.1 was used to define those who met DSM-IV (Diagnostic and Statistical Manual 4th edition) criteria for depressive disorder. Cox regression analysis controlled for potential covariates: age, sex, marital status, socioeconomic status, smoking, mean HbA(1c), diabetes complications and ulcer severity. The main outcome was mortality at 5 years.

RESULTS:
The prevalence of DSM-IV depressive disorder at baseline was 32.2% (n = 82). There were 92 (36.4%) deaths over the 5 years of follow-up. In the Cox regression (n = 246), after adjusting for covariates, baseline DSM-IV depressive disorder was significantly associated with a twofold increased risk of mortality for any depressive episode (HR 2.09, 95% CI 1.34, 3.25), minor (HR 1.93, 95% CI 1.00, 3.74) or major depressive disorders (HR 2.18, 95% CI 1.31, 3.65), compared with patients who were not depressed.

CONCLUSIONS/INTERPRETATION:
Depression is associated with a persistent twofold increased risk of mortality in people with their first DFU at 5 years.
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NewsBot · Jun 8, 2012

From the 2012 ADA Mtg
Psychological Stress and Diabetic Foot Ulcer Healing: Preliminary Findings
LORETTA VILEIKYTE, BIING JIUN-SHEN, LAURA CAMPBELL, ANDREW J. BOULTON, MATTHEW J. HARDMAN,

Research indicates that psychological stress (PS)-induced immunomodulation delays acute wound repair. Here we explored the potential role of PS in the more complex diabetic foot ulcer (DFU)-healing paradigm. Ninety three type 2 DM patients (84% male; mean age 57yrs) with plantar neuropathic DFU (University of Texas Classification: 69% grade 1A; 11% 1B; 16% 2A; and 4% 2B) completed baseline self-report measures of generalized (Perceived Stress Scale, PSS; Hospital Anxiety and Depression Scale, HADS; and State-Trait Anger Expression Inventory, STAXI) and DFU-specific PS (NeuroQoL-Interpersonal Burden (NeuroQoL-IP) and Patient Interpretation of Neuropathy (PIN) Scales: PIN-Amputation Worry and PIN-Anger at Docs). DFU-specific biomarkers (IL6, IL1-beta, MMP2 and MMP9) were determined via quantification of immunohistochemical tissue localization and normalized biopsy gene expression. Systemic biomarkers (IL6 and IL1-beta) were measured from patient serum via ELISA. Bivariate analyses revealed multiple measures of increased generalized and DFU-specific PS were associated with: a) decreased local IL1-beta at baseline: HADS-Depression (r=-.27; p<.001) and NeuroQoL-IP (r=-.38; p<.01); b) decreased MMP9: HADS-Depression (r=-.29; p<.05); PIN-Worry (r=-.34; p<.05) and PIN-Anger (r=-.37; p<.01); c) increased MMP2: PIN-Worry (r=.32; p<.05) and PIN-Anger (r=.31; p<.05). STAXI was associated with higher levels of baseline systemic IL6 (r=.32; p<.01). Intriguingly, greater than 80% DFU area reduction at 6 weeks was less likely in patients reporting more severe PIN-Worry (r=-.36; p<.01) and PIN-Anger (r=-.30; p<.01) and associated with higher baseline levels of systemic IL6 (r=-.29; p<.05) and local MMP2 (r=-.32; p<.05). These preliminary data identify potential psychological stress-induced biomarkers linking stress to DFU chronicity.
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NewsBot · Sep 21, 2013

Feelings of powerlessness and hope for cure in patients with chronic lower-limb ulcers.
Salomé GM, Alves SG, Costa VF, Pereira VR, Ferreira LM.
J Wound Care. 2013 Jun;22(6):300, 302-4.

OBJECTIVE:
To assess feelings of powerlessness and hope for cure in patients with chronic venous leg ulcers (VLUs) and diabetic foot ulcers (DFUs).
METHOD:
A clinical, analytical, descriptive study was conducted from April to September 2012 in a wound-care clinic in Brazil, on consecutive patients presenting withVLUs and DFUs. The Powerlessness AssessmentTool for Adult Patients (PAT) and the Herth Hope Index (HHI) were used.Total PAT scores range 12-60 and the higher the score, the stronger the feelings of powerlessness. The HHI ranges 12-48, with higher scores indicating higher levels of hope
RESULTS:
In total, 80 consecutive patients were recruited (40 VLU and 40 DFU). Mean PAT score was 53.3 +/- 9.6 (range 21-60) for DFU patients and 34.3 +/- 7.7 (range 21-60; p = 0.001) forVLU patients, suggesting these individuals had strong feelings of powerlessness. The mean HHI was 16.5 +/- 16.5 (range 12-40) for DFU patients and 27.5 +/- 27.5 (range 12-40; p = 0.001) for patients with VLUs, indicating low levels of hope.
CONCLUSION:
The results suggest that patients with DFUs had stronger feelings of powerlessness regarding their condition and less hope of recovery compared with patients with VLUs.
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NewsBot · Feb 27, 2014

Has the diabetic foot a significant impact on selected psychological or social characteristics of patients with diabetes mellitus?
Vladimíra Fejfarová MD., Ph.D., Alexandra Jirkovská, Prof. MD., Ph.D. , Eva Dragomirecká Dr., Ph.D., Frances Game, MD, Robert Bém, MD., Ph.D., Michal Dubský, MD., Veronika Wosková, MD., Marta Křížová, Jelena Skibová, Stephanie Wu, Prof., DPM, MSc.
source

Diabetic foot (DF) can alter some patient´s psycho-social characteristics due to, for example, therapeutic restrictions, or change of employment. The aim of our case-control study was to compare selected psychological and social characteristics between diabetic patients with and without the DF (controls).

Methods: 104 patients with and 48 without DF were included into our study. Both study groups were compared in terms of selected psychosocial characteristics.

Results: Compared to controls, patients with DF had a significantly worse quality of life in the area of health and standard of living as shown by lower physical health domain (12.7±2.8vs.14.7±2.5;p<0.001) and environment domain (14.1±2.2vs.15±1.8;p<0.01) that negatively correlated with diabetes duration (r = -0.061;p=0.003). None of the other parameters of QoL, or the stress impact differed significantly between the study groups. Patients with DF subjectively felt more depressed in contrast to controls (24.5vs.7.3%;p<0.05); however, the depressive tuning was objectively proven in higher percentage in both study groups (83.2vs.89.6; NS). A significantly lower level of educational achievement (p<0.01), more patients with disability pensions (p<0.01) and low self-support (p<0.001) were noted in patients with the DF compared to controls. In the subgroup of patients with a previous major amputation and DF (n=6), there were significantly worse outcomes as in the environment domain (p<0.01), employment status and stress readaptation (p<0.01) in contrast to the main study groups.

Conclusions: Patients with DF had a predominantly worse standard of living possibly due to the impairment of their socio-economic sphere and low self-support in contrast to non DF diabetic controls. In contrast to our expectations, patients with DF appeared to have good stress tolerability and mental health (with the exception of patients with previous major amputation) and did not reveal severe forms of depression or any associated consequences.
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NewsBot · May 3, 2014

Does the Diabetic Foot Have a Significant Impact on Selected Psychological or Social Characteristics of Patients with Diabetes Mellitus?
Fejfarová V, Jirkovská A, Dragomirecká E, Game F, Bém R, Dubský M, Wosková V, Křížová M, Skibová J, Wu S.
J Diabetes Res. 2014;2014:371

The aim of our case-control study was to compare selected psychological and social characteristics between diabetic patients with and without the DF (controls). Methods. 104 patients with and 48 without DF were included into our study. Both study groups were compared in terms of selected psychosocial characteristics. Results. Compared to controls, patients with DF had a significantly worse quality of life in the area of health and standard of living as shown by lower physical health domain (12.7 ± 2.8 versus 14.7 ± 2.5; P < 0.001) and environment domain (14.1 ± 2.2 versus 15 ± 1.8; P < 0.01) that negatively correlated with diabetes duration (r = -0.061; P = 0.003). Patients with DF subjectively felt more depressed in contrast to controls (24.5 versus 7.3%; P < 0.05); however, the depressive tuning was objectively proven in higher percentage in both study groups (83.2 versus 89.6; NS). We observed a significantly lower level of achieved education (P < 0.01), more patients with disability pensions (P < 0.01), and low self-support (P < 0.001) in patients with the DF compared to controls. In the subgroup of patients with a previous major amputation and DF (n = 6), there were significantly worse outcomes as in the environment domain (P < 0.01), employment status, and stress readaptation (P < 0.01) in contrast to the main study groups. Conclusions. Patients with DF had a predominantly worse standard of living. In contrast to our expectations, patients with DF appeared to have good stress tolerability and mental health (with the exception of patients with previous major amputation) and did not reveal severe forms of depression or any associated consequences.
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NewsBot · Jan 13, 2019

Screening for Depressive Symptoms in Patients with
Diabetic Foot using (CES-D) Scale: A Cross-Sectional
Study
Mervat Alsous et al
J Med J 2018; Vol. 52 (4):165-176

Aim: The aim of this study was to assess levels of depressive symptoms present in patients with diabetic
foot.
Methods: A convenience sampling method was used to recruit 108 patients with diabetic foot. After
having completed the Centre for Epidemiologic Studies Depression Scale CES-D scale, the patients'
demographic data and medical history were collected using pre-structured forms.
Results: Of the entire sample, 38.9% have CES-D score ≥27, which indicates risk of major depression.
Logistic regression analysis showed that retinopathy was significantly associated with increased
depressive symptoms among diabetic foot patients (odds ratio 3.41(p=0.017)). Taking supplement
therapy and not taking a combination of oral hypoglycemic agent and insulin treatment were
significantly associated with higher depressive symptoms (odds ratio 3.38 (p=0.022), 2.83 (p=0.030)),
respectively. Patients with primary education level have the highest odds ratio among all factors
associated with risk of major depression (OR, 4.07; p=0.003).
Conclusions: The risk of major deression among patients with diabetic foot in Jordan is high compared
to general diabetic population. This was associated with low educational level, retinopathy, taking
supplemt therapy, but not taking a combination of oral hypoglycemic agent and insulin. There is a need
for routine screening for depressive symptoms in patients with diabetic foot to help in the prevention,
early detection of depression and even referral to a psychiatrist.
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NewsBot · Nov 22, 2019

Predictive Risk Factor for Anxiety on Clients with Diabetic Foot Ulcer
Zaenal Abidin, Kusnanto, Bambang Purwanto, Supriyono, Edy Purwanto
Source

Anxiety is one of the psychological responses experienced by clients with diabetic ulcers that can affect glycemic control, serious complications, foot self-care behavior and slow the wound healing process. This research used to find out the factors that influence anxiety in clients with diabetic ulcers. This study was a retrospective analysis using medical records and diagnostic results of diabetic ulcers at Haji General Hospital, Surabaya, Indonesia. The sample was 951 people suffering from diabetic ulcers between January 2014 - December 2018. Samples were diagnosed with anxiety based on nursing diagnoses and fulfilling inclusion and exclusion criteria. The multivariable model of diabetic ulcer client anxiety was generated using stepwise logistic regression. There were independent variables affecting the anxiety of diabetic ulcer clients namely wound type (p < 0.015; OR = 0.91), health insurance (p <0.001; OR = 0.77) and gender (p <0.040; OR = 0.98) with the contribution of the four independent variables at 31% and the prediction accuracy of 86.6%. Gender of patients have a risk of 0.98 times experiencing anxiety, male contribute 0.64 times compared to female, so nursing interventions can be focused on wound care.
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NewsBot · Aug 10, 2023

The Diabetic Foot-Pain-Depression Cycle
Brandon M Brooks et al
J Am Podiatr Med Assoc. 2023 May-Jun;113(3):22-126. doi: 10.7547/22-126.

Background: More than 86,000 Americans with type 2 diabetes mellitus (T2DM) undergo nontraumatic lower-extremity amputations annually. The opioid-prescribing practice of podiatric surgeons remains understudied. We hypothesized that patients with T2DM who undergo any forefoot amputation while using antidepressant medication will have reduced odds of using opioids beyond 7 days.

Methods: We completed a retrospective cohort study examining patients with T2DM who underwent forefoot amputation (toe, ray, transmetatarsal). Data were restricted to patients with a hemoglobin A1c level less than 8.0% and an ankle-brachial index greater than 0.8. The outcome was use of postoperative opioids beyond 7 days. Patients received an initial opioid prescription of 7 days or less. We developed simple logistic regression models to identify the odds of a patient using opioids beyond 7 days by patient variables: age, race, sex, amputation level, body mass index, antidepressant medication use, and marital status. Variables with P < .1 in the univariate analysis were included in the multiple logistic regression model.

Results: Fifty patients met the inclusion criteria. Antidepressant use and marital status were the only statistically significant variables. Adjusting for marital status, patients with antidepressant use had decreased odds (odds ratio, 0.018; 95% confidence interval, 0.001-0.229; P = .002) of using opioids beyond 7 days after a diabetic forefoot amputation.

Conclusions: Patients with T2DM who used antidepressants had significantly reduced odds of using opioids beyond 1 week after forefoot amputations compared with those without antidepressant use. We proposed an underlying diabetic foot-pain-depression cycle. To break the cycle, podiatric surgeons should screen this population for depression preoperatively and postoperatively and not hesitate to make a mental health referral if warranted. Nontraumatic amputations can be a traumatic experience for patients; psychiatrists and other mental health providers should be members of limb preservation teams.
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NewsBot · Feb 28, 2024

Association between antidepressants and the risk of diabetic foot ulcers and amputation in antidepressant-naïve type 2 diabetes mellitus patients: A nested case-control study
Jinhyun Kim et al
Diabetes Research and Clinical Practice; 24 February 2024, 111591

Aims
Antidepressants are widely used by individuals with type 2 diabetes mellitus (T2DM). This study aimed to explore the correlation between antidepressant use, considering specific antidepressant subclasses or cumulative doses, and diabetic foot ulcer (DFU) risk.

Methods
This nested case-control study was conducted using a representative population-based Korean cohort database from 2002 to 2019. Participants with DFUs were matched with participants without DFUs based on age, sex, date of T2DM diagnosis, and follow-up duration. In total, 791 DFUs and 3900 controls were included. The association between antidepressant use or cumulative dose of each antidepressant subclass, DFU risk and amputation risk was examined using a conditional logistic regression model.

Results
Antidepressant ever-use was associated with an increased incidence of DFUs compared with non-use. Furthermore, an increase in DFU risk was evident with increasing cumulative antidepressant dosage, particularly among tricyclic antidepressant (TCA) ever-users and selective serotonin reuptake inhibitors (SSRIs) ever-users. Additionally, antidepressant ever-users displayed a higher risk of DFUs requiring amputation, which was consistently observed when the cumulative dosages of overall antidepressants and TCAs were considered.

Conclusion
Caution is advised when administering TCAs and SSRIs in antidepressant-naïve T2DM patients to reduce DFU and the consequent amputation risk.
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