• Users Online: 208
  • Print this page
  • Email this page


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 8  |  Issue : 2  |  Page : 27-31

Association of depression and its treatment on the outcome of diabetic foot ulcer


1 Department of Medicine, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan
2 Department of Biochemistry, Hamdard College of Medicine and Dentistry, Hamdard University, Karachi, Pakistan
3 Department of Research; Biochemistry, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan

Date of Web Publication11-Oct-2017

Correspondence Address:
Muhammad Yakoob Ahmedani
Plot No. 1-2, II-B, Nazimabad No. 2, Karachi 74600
Pakistan
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_10_17

Get Permissions

  Abstract 


Aim: This study aimed to assess depression symptoms among patients with diabetic foot ulcer and to compare the outcome of diabetic foot ulcer between normal participants and participants with depressive symptoms. Methodology: This prospective, observational study was conducted at Baqai Institute of Diabetology and Endocrinology, after getting approval from ethics committee. Patients who were attending the foot clinic were invited to participate in the study. Diabetic foot ulcers were classified according to the University of Texas classification criteria. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9). Both groups were given standard diabetes and foot care treatment. In addition, antidepressant treatment was given to the participants with depressive symptoms for 3 months. After 3 months, PHQ-9 was again administered to the participants with depressive symptoms, and the outcome of foot ulcer was noted and compared to baseline data. Results: Of the total participants (n = 105), nearly half of them were found to have depressive symptoms (n = 53, 50.4%). At baseline, no significant difference was found in the distribution of hypertension, history of smoking and duration, grading and type of ulcers between normal participants and participants with depressive symptoms. Three months of antidepressant treatment brought significant improvement in the mean depression score (P ≤ 0.05). After 3 months, healing time of ulcers, rate of minor and major amputations, patients on treatment and patients who lost to follow-up were comparable between the groups. Conclusions: In this study, every second patient with diabetic foot ulcer was found to have depressive symptoms. Anti-depressive treatment alleviated depression and made foot ulcer outcome comparable to non-depressed patients.

Keywords: Antidepressant effect, depression, foot ulcer outcome


How to cite this article:
Ahmedani MY, Ahsan S, Ul Haque MS, Fawwad A, Basit A. Association of depression and its treatment on the outcome of diabetic foot ulcer. J Diabetol 2017;8:27-31

How to cite this URL:
Ahmedani MY, Ahsan S, Ul Haque MS, Fawwad A, Basit A. Association of depression and its treatment on the outcome of diabetic foot ulcer. J Diabetol [serial online] 2017 [cited 2017 Oct 18];8:27-31. Available from: http://www.journalofdiabetology.org/text.asp?2017/8/2/27/216456




  Introduction Top


Diabetic foot disease is potentially one of the most distressing and disabling complications of diabetes.[1] Published data indicated that the prevalence of diabetic foot ulceration in the diabetic population is 4%–10%.[2] It is estimated that about 5% of all patients with diabetes present with a history of foot ulceration and 5%–24% of them will finally lead to limb amputation within a period of 6–18 months.[3] These ulcers result in non-traumatic lower limb amputations in 40%–70% of patients with diabetes.[4] Diabetic foot ulcer is one of the most frequent causes of hospitalisation, and economically most costly complications of diabetes are largely due to long healing time and often poor outcome.[4],[5] An analysis of the cost of treatment of various long-term diabetic complications revealed that the average cost of treating and managing diabetes-related foot complications was the highest among all other complications of diabetes.[6]

Depression is adversely associated with diabetes, from incidence to mortality.[7] Patients with diabetes and comorbid depression were found to have greater symptom severity, increased disease burden, disability in work and use of medical services.[8] A meta-analysis demonstrated a clinically significant relationship between depression and diabetes complications (both micro- and macro-vascular) and its severity.[9] The development of depression is usually considered as a secondary response to the onset of complications, but depression might also play a primary role in the development or exacerbation of diabetes complications.[8]

Limited data are available regarding the association of depression and its treatment on the outcome of diabetic foot ulcer from Pakistan. Similarly, the effect of antidepressant treatment on the outcome of diabetic foot ulcers is also not reported widely. Hence, the present study was designed to assess depression symptoms among patients with diabetic foot ulcer and to compare the outcome of diabetic foot ulcer between normal participants and participants with depressive symptoms.


  Methodology Top


This prospective, observational study was conducted at the foot clinic of Baqai Institute of Diabetology and Endocrinology (BIDE) after obtaining signed informed consent from the consented patients. Ethical approval of the study was obtained from the Institutional Review Board of BIDE. The study was conducted according to the guidelines of Helsinki Declaration.

All patients with Type 2 diabetes attending the clinic during the induction period (May 2012–December 2012) were invited to participate in the study. Patients on dialysis or having creatinine above normal range, patients with Type 1 diabetes and pregnant women were excluded from the study.

Data on demographic, anthropometric, clinical and biochemical characteristics at baseline and 3 months after the treatment were extracted from the health management information system of BIDE. Diabetic foot ulcers were classified according to the University of Texas classification criteria. This classification deals with ulcer depth (grade) and includes the presence of infection and ischaemia (stage).[10] The presence of depressive symptoms among consented patients was assessed by the administration of a questionnaire, Patient Health Questionnaire-9 (PHQ-9).[11]

After initial screening of depression by the administration of PHQ-9, all patients with PHQ score >9 were evaluated for the presence of depressive symptoms by their respective consultants because score >9 requires treatment for depression. After physician evaluation, antidepressant should be given for 9–12 months.[12]

After 3 months, PHQ-9 was administered again to the depressed patients to assess the effect of medicine on the depressive symptoms and glycaemic control. The foot ulcer outcomes and healing time were compared with participants without depressive symptoms.

Statistical analysis

Data were entered in Microsoft Excel (version 2010) that were later imported to SPSS (Version 15.0.1, SPSS Inc, Chicago, IL, USA) for statistical analysis. Confidence interval of the study was set at 95% or P ≤ 0.05. Effect of antidepressant treatment on depression and glycaemic control was assessed by comparison of mean PHQ-9 scale and mean haemoglobin A1c (HbA1c), respectively, of the patients with depressive symptoms before and after treatment. Foot ulcer outcomes were assessed by group comparisons between groups after 3 months of treatment.


  Results Top


A total of 105 patients with diabetic foot ulcer including 79 (75.2%) men and 26 (24.8%) women were evaluated. The mean (± standard deviation) age and duration of diabetes were 52.72 (±10.81) years and 14.85 (±8.60) years, respectively. Blood pressure was high (≥130/80 mmHg) in 44.7% (n = 47) of patients. The baseline characteristics of cohort are reported in [Table 1]. Of the patients assessed, 50.4% (n = 53) fulfilled the criteria for depression on PHQ-9 score (≥9) while 49.5% (n = 52) had no clinically significant depression. Predominantly, males in the present study had foot ulcers but most of the females with foot ulcers were depressed. Comparison of clinical and biochemical variables of depressed and non-depressed group is shown in [Table 2]. A non-significant difference in the duration of diabetes, distribution of hypertension, history of smoking and duration and grading and type of ulcers between groups was observed [Table 2].
Table 1: Baseline characteristics of the study population (n=105)

Click here to view
Table 2: Comparison of anthropometric, clinical and biochemical variables of the study groups

Click here to view


Three months of antidepressant treatment to the patients with PHQ-9 score ≥9 brought a significant improvement in the mean depression score (P ≤ 0.05) [Figure 1] and [Figure 2].
Figure 1: Effect of antidepressant on the depression score of depressed patients with foot ulcer

Click here to view
Figure 2: Comparison of glycaemic control of non-depressed and treated depressed diabetic foot ulcer patients before and after treatment

Click here to view


Outcomes of the foot ulcers between groups were shown in [Table 3]. After 3 months, 60% of the ulcers healed completely in the non-depressed group whereas 40% healed in the depressed group (P > 0.05). Similarly, ulcers' healing time and rate of major and minor amputations also did not differ significantly between groups.
Table 3: Comparison of effect of antidepressant treatment on the outcome of foot ulcer

Click here to view



  Discussion Top


Our study found an exceptionally higher rate of depressive symptoms in patients with diabetic foot ulcers. It was more frequent in the female patients with foot ulcers. Contrary to non-depressed diabetic foot patients, depressed patients were younger. Antidepressant treatment to the depressed group brought a significant improvement in the depression score. The foot ulcer outcomes were comparable to non-depressed group.

In the present study, we observed higher rate of depressive symptoms among patients with diabetic foot ulcer compared to a large prospective cohort study.[13] This variation in the reported frequency of depression may be attributed to difference in the studied population, clinical settings and associated comorbidities. However, the presence of increased frequency of depression among diabetic foot patients supports the hypothesis that depression may influence the onset of foot ulcers. Recently, this hypothesis is evidently supported by a number of longitudinal studies.[14],[15] A cohort study that followed depressed patients with Type 2 diabetes for more than 4 years concluded that the incidence of diabetic foot ulcers was twice more common in patients with depression and Type 2 diabetes than patients with Type 2 diabetes alone.[15]

In the present study, we observed that foot ulcers are found to be high in males. This was observed in other studies, probably due to greater exposure of males to external environment and trauma.[16] However, depression was more frequently observed in females with diabetes and foot ulcers. This finding is consistent with other published studies with reported increased preponderance in prevalence, incidence and morbidity risk of depressive disorders in female patients with diabetes. Depressive symptoms are very common and high in women compared to men due to hormones.[17],[18],[19]

Although the elderly (age 65 or more) are particularly at a high risk for depression, depression can occur at any age.[20] In the present study, compared to non-depressed patients, patients with depression were younger. Presence of depression in younger diabetic foot ulcer patients could be due to the influence of social, psychological and economic factors such as restricted life, social isolation and difficulties in professional practices. Diabetic foot ulcer is a potentially debilitating condition. It requires long healing time and long period of work off days, posing economic burden that may perpetuate depression among the young.[21] Furthermore, the high cost of ulcer treatment further complicates the situation.[22]

The presence of depression has major consequences for individuals with diabetes. However, several studies showed that depression can be well treated in individuals with diabetes. A number of treatment options are available for the treatment of depression.[23],[24],[25]

In the present study, treatment with antidepressant medications (escitalopram, a selective serotonin reuptake inhibitor) significantly improved mean depression score of the patients with depressive symptoms. Although the overall glycaemic control of the study population including both depressed and non-depressed patients was poor, this finding was not surprising as this is a universal phenomenon. The mean HbA1c of both depressed and non-depressed groups did not improve significantly over 3 months [Figure 2], but it had neither worsen during this period. Reasons for uncontrolled glycaemic range could be lack of motivation among patients and resources required for monitoring (including glucometers and strips) as majority of these patients were poor.[7],[26],[27],[28]

It has been widely reported in the literature that patients with depressive symptoms and diabetes have large and extensive ulcers at presentation with a high risk of non-healing and recurrence. In the present study, the presentation of foot ulcer was identical in both the groups. After 3 months of antidepressant treatment, comparable number of foot ulcers healed completely in both groups. Similarly, healing time, rate of minor and major amputations and patients on treatment were not different between the groups. The depression score significantly improved as a result of treatment, with comparable foot outcomes.

Strengths and limitations

Findings of the present study demand careful interpretation. Small sample size, non-randomisation of studied population and lack of assessment of depression and biochemical variables after 3 months in the non-depressed group restrict generalizability of our findings. Our study, however, opens the arena of conducting similar study on a large scale for validity.


  Conclusions Top


In this study, every second patient with diabetic foot ulcer was found to have depressive symptoms. Anti-depressive treatment along with other metabolic control can be helpful in improving the outcome.

Acknowledgement

We appreciate the support of Mr. Bilal Tahir (research coordinator), Ms. Sidra Siddiqui (statistician) and Research Department of Baqai Institute of Diabetology and Endocrinology, for induction and monitoring of patients and analysis of data.

Financial support and sponsorship

We acknowledge the support of Lundbeck Pakistan LTD for providing financial support for the study.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alexiadou K, Doupis J. Management of diabetic foot ulcers. Diabetes Ther 2012;3:4.  Back to cited text no. 1
    
2.
Katsilambros N, Dounis E, Makrilakis K, Tentolouris N, Tsapogas P. Atlas of the Diabetic Foot. 2nd ed. Oxford: Wiley-Blackwell; 2010.  Back to cited text no. 2
    
3.
Moxey PW, Gogalniceanu P, Hinchliffe RJ, Loftus IM, Jones KJ, Thompson MM, et al. Lower extremity amputations – A review of global variability in incidence. Diabet Med 2011;28:1144-53.  Back to cited text no. 3
    
4.
Armstrong DG, Lavery LA. Diabetic foot ulcers: Prevention, diagnosis and classification. Am Fam Physician 1998;57:1325-32, 1337-8.  Back to cited text no. 4
    
5.
Kumpatla S, Kothandan H, Tharkar S, Viswanathan V. The costs of treating long-term diabetic complications in a developing country: A study from India. J Assoc Physicians India 2013;61:102-9.  Back to cited text no. 5
    
6.
Carls GS, Gibson TB, Driver VR, Wrobel JS, Garoufalis MG, Defrancis RR, et al. The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers. J Am Podiatr Med Assoc 2011;101:93-115.  Back to cited text no. 6
    
7.
Egede LE, Nietert PJ, Zheng D. Depression and all-cause and coronary heart disease mortality among adults with and without diabetes. Diabetes Care 2005;28:1339-45.  Back to cited text no. 7
    
8.
Katon WJ. The comorbidity of diabetes mellitus and depression. Am J Med 2008;121 11 Suppl 2:S8-15.  Back to cited text no. 8
    
9.
Lustman PJ, Anderson RJ, Freedland KE, de Groot M, Carney RM, Clouse RE. Depression and poor glycemic control: A meta-analytic review of the literature. Diabetes Care 2000;23:934-42.  Back to cited text no. 9
    
10.
Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996;35:528-31.  Back to cited text no. 10
    
11.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13.  Back to cited text no. 11
    
12.
Available from: http://www.ubcmood.ca/sad/PHQ-9.pdf. [Last accessed on 2015 Jan 28].  Back to cited text no. 12
    
13.
Ismail K, Winkley K, Stahl D, Chalder T, Edmonds M. A cohort study of people with diabetes and their first foot ulcer: The role of depression on mortality. Diabetes Care 2007;30:1473-9.  Back to cited text no. 13
    
14.
Ali S, Stone MA, Peters JL, Davies MJ, Khunti K. The prevalence of co-morbid depression in adults with type 2 diabetes: A systematic review and meta-analysis. Diabet Med 2006;23:1165-73.  Back to cited text no. 14
    
15.
Williams LH, Rutter CM, Katon WJ, Reiber GE, Ciechanowski P, Heckbert SR, et al. Depression and incident diabetic foot ulcers: A prospective cohort study. Am J Med 2010;123:748-54.e3.  Back to cited text no. 15
    
16.
Ngwogu KO, Umez-Emeana EC, Ngwogu AC. The burden of diabetic foot ulcers in Aba, Abia State, Nigeria. Int J Basic Appl Innov Res 2013;2:118-24.  Back to cited text no. 16
    
17.
Parry BL. Sex hormones, circadian rhythms and depressive vulnerability. Depression 1995;3:43-8.  Back to cited text no. 17
    
18.
Silberg J, Pickles A, Rutter M, Hewitt J, Simonoff E, Maes H, et al. The influence of genetic factors and life stress on depression among adolescent girls. Arch Gen Psychiatry 1999;56:225-32.  Back to cited text no. 18
    
19.
Angold A, Costello EJ, Worthman CM. Puberty and depression: The roles of age, pubertal status and pubertal timing. Psychol Med 1998;28:51-61.  Back to cited text no. 19
    
20.
Richardson LK, Egede LE, Mueller M, Echols CL, Gebregziabher M. Longitudinal effects of depression on glycemic control in veterans with type 2 diabetes. Gen Hosp Psychiatry 2008;30:509-14.  Back to cited text no. 20
    
21.
Kuruvilla A, Jacob KS. Poverty, social stress and mental health. Indian J Med Res 2007;126:273-8.  Back to cited text no. 21
[PUBMED]  [Full text]  
22.
Alonso-Morán E, Satylganova A, Orueta JF, Nuño-Solinis R. Prevalence of depression in adults with type 2 diabetes in the Basque Country: Relationship with glycaemic control and health care costs. BMC Public Health 2014;14:769.  Back to cited text no. 22
    
23.
Lustman PJ, Freedland KE, Griffith LS, Clouse RE. Fluoxetine for depression in diabetes: A randomized double-blind placebo-controlled trial. Diabetes Care 2000;23:618-23.  Back to cited text no. 23
    
24.
Williams JW Jr., Katon W, Lin EH, Nöel PH, Worchel J, Cornell J, et al. The effectiveness of depression care management on diabetes-related outcomes in older patients. Ann Intern Med 2004;140:1015-24.  Back to cited text no. 24
    
25.
Petrak F, Herpertz S. Treatment of depression in diabetes: An update. Curr Opin Psychiatry 2009;22:211-7.  Back to cited text no. 25
    
26.
de Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ. Association of depression and diabetes complications: A meta-analysis. Psychosom Med 2001;63:619-30.  Back to cited text no. 26
    
27.
Clouse RE, Lustman PJ, Freedland KE, Griffith LS, McGill JB, Carney RM. Depression and coronary heart disease in women with diabetes. Psychosom Med 2003;65:376-83.  Back to cited text no. 27
    
28.
Black SA, Markides KS, Ray LA. Depression predicts increased incidence of adverse health outcomes in older Mexican Americans with type 2 diabetes. Diabetes Care 2003;26:2822-8.  Back to cited text no. 28
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Methodology
Results
Discussion
Conclusions
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed69    
    Printed2    
    Emailed0    
    PDF Downloaded13    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]