Depression symptoms in people with diabetes attending outpatient podiatry clinics for the treatment of foot ulcers

Abstract

Background: The purpose of this study was to examine the prevalence of depressive symptoms, diabetes self-management, and quality of life in people with diabetes and foot ulcers. Ulcer status, mortality and amputations were also assessed at six months follow-up. Methods: This was a cross-sectional survey of people attending outpatient podiatry clinics at a major tertiary referral hospital. Depressive symptoms were measured using the Patient Health Questionnaire (PHQ). Diabetes self-care was assessed using the Summary of Diabetes Self Care Activities (SDSCA) measure. Health-related quality of life was measured using the physical component summary score (PCS) and the mental component summary score (MCS) of the SF-12. Results: Of the 60 participants in the study 14 (23.3%) reported mild symptoms of depression (PHQ score 5-9) and 17 (28.3%) moderate to severe depressive symptoms (PHQ score > 9). Twenty-one (35%) met the criteria for previously recognized depression (on antidepressants and/or a diagnosis of depression in the last 12 months) and 17 (28.3%) for depression not previously recognized (PHQ > 4). Seventeen (28%) participants had been receiving antidepressant treatment for a median duration of 104 weeks (IQR 20, 494 weeks). Despite antidepressant treatment 12 participants (70.6% of those taking antidepressants) still reported moderate to severe depressive symptoms at the time of the study. Patients with PHQ scores > 4 reported poorer adherence to diabetes self-care activities including general diet, exercise, blood sugar monitoring and foot care when compared to those participants with PHQ scores < 5. No association was found between physical functioning (PCS) and depressive symptoms. Decreasing mental wellbeing (MCS) was associated with increasing depressive symptoms. At six months follow-up, there were three deaths and three amputations in participants with PHQ scores > 4 compared with no deaths and 2 amputations in participants with PHQ scores < 5. There was no association between depressive symptoms and ulcer healing or ulcer recurrence at the six-month follow-up. Conclusions: This study found a high prevalence of depressive symptoms both recognized and unrecognized in people with diabetes and foot ulcers. Depressive symptoms were associated with overall poorer diabetes self-management and health-related quality of life (HRQoL). There was no association between depressive symptoms and ulcer outcomes at six-months follow-up.

Depression in diabetic foot ulcer: Associated factors and the impact of perceived social support and anxiety on depression

“…According to estimates, 15% of patients may experience a DFU through their life 1 and face with significant risk of amputation, irrespective of socioeconomic group and geographical region 2‐4 . Furthermore, approximately two‐thirds of DFU will heal within 6 months while in 60% of individuals, the ulceration may reoccur within 12 months 5 . Additionally, DFU management exerts directly a heavy economic burden on the health care system of every country, globally, while indirectly, the cost mainly involves loss in productivity attributed to disability and premature mortality 6,7 …”

“…Depression, seems to be higher individuals with diabetes mellitus, increases the risk of diabetic complications, is associated with delay in wound healing, and has a threefold increased risk of mortality within 18 months after first foot ulcer 5 . It is noteworthy that depression may occur as a response to DFU foot ulceration while is also associated with increased risk of developing DFU compared with people with diabetes and no depression 5,8 …”

A cost‐effectiveness analysis of optimal care for diabetic foot ulcers in Australia

“…Among patients diagnosed with diabetes, the annual incidence of developing foot ulcers ranges from 1% to 4% . DFUs not only significantly increase the risk of poor quality of life, morbidity and mortality of affected individuals but also impose a large economic burden on patients and the health care system. Recent studies from developed countries report substantial estimated national annual costs incurred from DFU care, ranging from $547 million in hospitalisation costs in Canada and £580 million in health system costs in England , to US$9–13 billion costs incurred by Medicare and private health insurers in the USA .…”

Progression to unscheduled hospital admissions in people with diabetes: a qualitative interview study

“…This supports the current findings where participants with existing ulceration and/or amputation demonstrated difficulty in reconciling their experiences with their perceptions and subsequent health behaviours. Although not specifically recorded, multiple participants discussed comorbid depression and psychological difficulties, which is supported by research showing strong associations between foot ulceration and depression [37][38][39][40]. This suggests a need for not only improved education but also increased psychosocial support to encourage acknowledgement of illness severity, improve understanding of timely preventative self-care practice, and engagement with services at appropriate junctures to avoid the progression of illness to requiring admissions.…”