Depression predicts first but not recurrent diabetic foot ulcers

Abstract

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.

Health-Related Quality of Life Predicts Major Amputation and Death, but Not Healing, in People With Diabetes Presenting With Foot Ulcers: The Eurodiale Study

“…Depression is quite common in people with diabetes, and it predicts DFU (26). In people with DFU, depression has been found in one-third of patients, predicting increased mortality (27), but other studies did not find an effect of depression (28).…”

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“…First, we suggest that emotional distress be considered a common core construct that underlies diabetes distress, depressive symptoms, ‘subclinical depression’ and major depressive disorder. Second, given the significant incremental relationships between measures of depressive symptoms and measures of self-management [14,18], diabetes complications and mortality risk [1,42], emotional distress is best considered a continuous, scalable psychological characteristic rather than a discrete co-morbid clinical condition.…”

Assessing Health-Related Quality of Life in Patients With Diabetic Foot Disease: Why Is It Important and How Can We Improve? The 2017 Roger E. Pecoraro Award Lecture

“…Postural instability and pain, as measured from the NeuroQol, are significantly associated with noncompliance with off-loading regimens in patients with diabetes with foot ulcers (45). Identifying emotional distress in patients with diabetes with neuropathy is important because depression is associated with development of an index foot ulcer (46). In addition, the presence of neuropathy in patients with diabetes is independently associated with depression (47).…”