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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.
Re: Coping style and depression influence the healing of diabetic foot ulcers
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
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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.
Re: Coping style and depression influence the healing of diabetic foot ulcers
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.
Re: Coping style and depression influence the healing of diabetic foot ulcers
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
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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.
Re: Coping style and depression influence the healing of diabetic foot ulcers
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,
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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.
Coping style and depression influence the healing of diabetic foot ulcers
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