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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 8
| Issue : 2 | Page : 27-31 |
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Association of depression and its treatment on the outcome of diabetic foot ulcer
Muhammad Yakoob Ahmedani1, Shahid Ahsan2, Muhammad Saif Ul Haque1, Asher Fawwad3, Abdul Basit1
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 Publication | 11-Oct-2017 |
Correspondence Address:
Muhammad Yakoob Ahmedani
Plot No. 1-2, II-B, Nazimabad No. 2, Karachi 74600
Pakistan
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jod.jod_10_17
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 |
| Introduction | |  |
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 | | |
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 | | |
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 2: Comparison of anthropometric, clinical and biochemical variables of the study groups
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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
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 | Figure 2: Comparison of glycaemic control of non-depressed and treated depressed diabetic foot ulcer patients before and after treatment
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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
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| Discussion | | |
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 | | |
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.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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