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Innovation Report are carrying this story: Mental Health Linked to Amputation Risk in Diabetic Veterans
For U.S. veterans with diabetes, lower scores on a test of mental health functioning are associated with an increased risk of major amputations, reports a study in the November/December issue of the journal General Hospital Psychiatry.
"Our findings suggest that foot care programs need to assess individuals for mental health functioning as a risk factor and to develop appropriate interventions to counteract this higher risk of major amputation," write the study authors, led by Chin-Lin Tseng, Dr.P.H., of the VA New Jersey Health Care System, East Orange, N.J.
Dr. Tseng and colleagues analyzed a database of nearly 115,000 patients with diabetes who received care at Veterans Health Administration clinics from 1998 to 2000. All of the veterans were asked to complete a measure of mental health functioning.
Scores for mental health functioning were evaluated as a risk factor for diabetes-related amputations of the foot and leg. During 2000, "major" amputations (ankle or above) were required in 450 patients, while 431 underwent "minor" amputations (toes to ankle).
Veterans with lower scores for mental health functioning were at increased risk for amputations. This was so even when other important risk factors—including poor control of diabetes, smoking, less-frequent health care, and obesity—were taken into account. The overall rate of major amputations was 0.5 percent in veterans with below-average mental health scores, compared to 0.3 percent in those with above average scores and 0.2 percent for those at the highest level of mental health functioning.
On analysis including all risk factors, each five-point increase in mental health score was associated with a five percent decrease in the risk of major amputations. After adjustment, mental health functioning was no longer a significant risk factor for minor amputations.
Mental health scores were higher for veterans who had above a high school education, who were not obese, and who were not considered poor.
Amputations are a major complication of diabetes. Most studies of amputation risk factors have focused on medical conditions—for example, foot problems such as ulcers or infections or control of diabetes. Although some research has suggested that mental health care may affect the risk of diabetes-related amputations, the new study is the first to address this issue directly.
The results suggest that poor mental health functioning is an important risk factor for major amputations in diabetic veterans. Although the study cannot prove any cause-and-effect relationship, Dr. Tseng and colleagues believe that problems with mental health may interfere with needed diabetes care, including foot care.
The researchers urge medical professionals and patients to be aware of the possible link between mental health and amputation risk. They conclude, "Identifying patients who are at higher risk for major amputations due to poor mental health functioning may allow the dedication of resources and services to more closely supervise and manage their podiatric needs, perhaps leading to fewer amputations."
The objective of this study was to evaluate the association between mental health functioning and lower extremity amputations (LEAs) in veterans with diabetes.
A retrospective study of 1999 Large Veteran Health Survey (LVHS) respondents with diabetes who were Veterans Health Administration clinic users in fiscal years (FYs) 1998–2000 was performed. The outcome measure was type of LEAs (major, minor and none) in FY 2000. The primary independent variable was mental health functioning [adapted Medical Outcomes Study Short Form-36 mental component summary (MCS) score, with higher being better] from the LVHS. Multinomial logistic regressions were performed to evaluate the association between MCS score and LEAs, adjusting for control variables derived from FY 1999.
Of the 114,890 individuals included in the study, there were 450 (3.9 per 1000 individuals) major and 431 (3.8 per 1000 individuals) minor LEAs in FY 2000. Individuals with major and minor LEAs had lower mean MCS scores than those without LEAs (39.9, 42.2 and 43.4). After controlling for other independent variables, a five-point increase in MCS score was associated with a 5% decrease in the risk of major LEAs (odds ratio [OR]=0.95; 95% confidence interval [95% CI]=[0.94, 0.96]) but was not related to minor LEAs (OR=1.01; 95% CI=[0.97, 1.05]).
Conclusion Footcare programs need to assess individuals for mental health functioning as a risk factor and to develop appropriate interventions to reduce the risk of major amputation.
Re: Mental health issues linked to diabetes amputations
An exploratory phenomenological study exploring the experiences of people with systemic disease who have undergone lower limb amputation and its impact on their psychological well-being
Elaine D Washington, Anita E Williams Prosthet Orthot Int November 18, 2014
Background: Amputation is a life-changing event accompanied by challenges for the affected person with time-dependent depression often used to quantify its level of impact on their psychological well-being. There are varied factors that contribute to this and its persistence. The aim of this study was to explore the experiences over time of people with diabetes and/or peripheral vascular disease following an amputation and the impact on their psychological well-being.
Objectives: To develop an understanding of the experience of living with an amputation and a chronic condition in order to help clinicians identify those in need of counselling support.
Study design: A qualitative study utilising an iterative approach in line with the philosophy of interpretive phenomenology.
Methods: Six participants who had experienced a lower limb amputation associated with peripheral vascular disease/diabetes were interviewed on two occasions (baseline and 4 months). An interpretative phenomenological approach was utilised for both data collection and analysis.
Results: For these participants, amputation was part of the chronology of their chronic disease. It was the individual’s variable experience of health which impacted their psychological well-being rather than the length of time since amputation.
Conclusions: The multivariable experience of amputation means that individually tailored counselling/psychological support is recommended.
Clinical relevance An understanding of how the experience of living with an amputation and a chronic condition may change over time will help clinicians to identify the ongoing need for counselling support.
Re: Mental health issues linked to diabetes amputations
Health-related profiles of people with lower limb loss
Dagmar Amtmann, PhD, Sara J. Morgan, PhD, CPO, Jiseon Kim, PhD, Brian J. Hafner, PM & R: Article in Press
To build profiles of self-reported health indicators to examine differences and similarities between people with LLL and a normative sample, and (2) Compare health indicators between subgroups based on level and etiology of limb loss.
1,091 adults with unilateral LLL participated in this study. Eligibility criteria included LLL resulting from trauma or dysvascular complications and regular use of a prosthesis.
Main Outcome Measures
Patient-Reported Outcomes Measurement Information System 29-item profile (PROMIS-29) version 1.0 measures physical function, pain interference, fatigue, sleep disturbance, anxiety, depression and satisfaction with participation in social roles. The norms are based on 5,239 individuals representative of the U.S. general population in gender, age, race, ethnicity and education.
People with LLL reported statistically significantly worse physical function, pain interference and satisfaction with participation in social roles and significantly less fatigue than the norm. People with transfemoral (i.e., above-knee) amputation significantly differed from people with transtibial (i.e., below-knee) amputation on physical function. Similarly, people with amputation due to trauma and dysvascular etiology significantly differed on physical function and satisfaction with social roles after adjusting for relevant clinical characteristics.
People with LLL generally report worse physical function, pain interference and satisfaction with social roles when compared to norm. People with dysvascular amputation reported worse physical function and satisfaction with social roles than people with traumatic amputation. Health indicator profiles are an efficient way of providing clinically meaningful information about numerous aspects of self-reported health in people with LLL.
Re: Mental health issues linked to diabetes amputations
Suicidal Ideation Among Individuals With Dysvascular Lower Extremity Amputation
Aaron P. Turner, PhD, Tiffany M. Meites, PhD, Rhonda M. Williams, PhD, Alison W. Henderson, PhD, Daniel C. Norvell, PhD, Kevin N. Hakimi, MD, Joseph M. Czerniecki, MD Archives of Physical Medicine and Rehabilitation; in press
To examine the estimated prevalence and correlates of suicidal ideation (SI) among individuals 1 year after a first lower extremity amputation (LEA).
Four medical centers.
A referred sample of patients (N=239), primarily men, undergoing their first LEA because of complications of diabetes mellitus or peripheral arterial disease, were screened for participation between 2005 and 2008. Of these patients, 136 (57%) met study criteria and 87 (64%) enrolled; 70 (80.5%) of the enrolled patients had complete data regarding SI at 12-month follow-up.
Main Outcome Measures
SI, demographic/health information, depressive symptoms, mobility, independence in activities of daily living (ADL), satisfaction with mobility and ADL, medical comorbidities, social support, self-efficacy.
At 12 months postamputation, 11 subjects (15.71%) reported SI; of these, 3 (27.3%) screened negative for depression. Lower mobility, lower satisfaction with mobility, greater impairment in ADL, lower satisfaction with ADL, lower self-efficacy, and depressive symptoms were all correlated with the presence of SI at a univariate level; of these, only depressive symptoms remained significantly associated with SI in a multivariable model.
SI was common among those with recent LEA. Several aspects of an amputee's clinical presentation, such as physical functioning, satisfaction with functioning, and self-efficacy, were associated with SI, although depression severity was the best risk marker. A subset of the sample endorsed SI in the absence of a positive depression screen. Brief screening for depression that includes assessment of SI is recommended.
Objective: The aim of this study was to examine associations between a cognitive screen and four neuropsychologic tests administered at both 6 wks and 4 mos after amputation and five functional outcomes measured 12 mos after lower extremity amputation.
Design: This study includes a prospective cohort from four medical centers. Participants were primarily male Veterans experiencing their first lower extremity amputation as a result of complications of diabetes mellitus or peripheral arterial disease. Of those eligible, 87 (64%) enrolled; 75 (86%) were retained at 12 mos. Measures included demographic/health information, four neuropsychologic measures, the Locomotor Capability Index–5, the Gronigen Activity Restriction Scale, prosthetic use, community participation, and social integration.
Results: Better performance on the Short Portable Mental Status Questionnaire at 4 mos was associated with greater 12-mo mobility and social integration. Better attention and working memory abilities 6 wks after amputation were associated with increased 12-mo prosthetic wear; and at 4 mos after amputation, with greater 12-mo mobility. Better verbal memory at 6 wks was associated with greater 12-mo social integration and community participation as well as increased prosthetic wear.
Conclusions: These findings highlight the potential value in including a brief, formal cognitive assessment in addition to a general mental status screen. Specific domains of cognitive function are differentially associated with functional outcomes and may inform amputation rehabilitation decisions.