Abstract
A chronic leg ulcer is a debilitating illness, owing to the local condition of the wound and a decrease in physical activity and productivity, resulting in anxiety and depression among patients. The study aimed to find any association of anxiety and depression in the healing of chronic wounds. A total of 125 patients with chronic leg ulcers were enrolled in the study. HADS questionnaire assessment followed the local wound examination in all patients. A follow‐up assessment of the ulcer was done after appropriate local treatment, and data analysed with the HADS scale. In the present study, the ROC curve showed a cutoff value of 14 for the HADS score in predicting ulcer status (non‐healing vs healed) after 30 days. A total of 54.4% (68) patients had a HADS score ≥ 14 and 39% (49) were true positive for the non‐healing wound at a 1‐month follow‐up. This study revealed a sensitivity and specificity of 83.1% and 71.2%, respectively (P‐value <.001), and diagnostic accuracy of 76.8%, for HADS score > 14 in the detection of non‐healing ulcers. Chronic leg ulcers should be subjected to HADS assessment and if found significant corrective measures must be instituted for improving wound healing.
Keywords: chronic leg ulcer, chronic wound and cut off value of HADS, leg ulcer and HADS, leg ulcer and psychological association, non‐healing leg ulcer
1. INTRODUCTION
A chronic leg ulcer is defined as a breach in the skin below‐knee persisting for more than 6 weeks without any tendency to heal even after three or more months of appropriate treatment. It is a vicious cycle of ulceration, healing, and re‐ulceration in individuals suffering from chronic leg ulcers. Chronic leg ulcers are difficult to heal and have a tendency to recur, especially venous ulcers. 1 It is a debilitating illness because of associated pain, wound discharge, swelling, and foul smell that leads to a decrease in physical activity and productivity and ultimately affects patient's quality of life. All these lead to anxiety and depression among patients. 2 Non‐healing of the ulcer is not only related to local factors, instead there are psychological stress factors too, which cause delayed wound healing. Psychosocial factors act on the immune system and might make a patient more susceptible to infection and further compromise wound healing. 2 Common causes of leg ulcers are venous diseases, arterial diseases, and neuropathy. Specific questionnaires have been used to assess the psychological factors in the form of levels of anxiety and depression. In this study, the authors have used the hospital anxiety and depression scale (HADS) in patients with a chronic leg ulcer. HADS is a brief and widely used questionnaire‐based method for screening clinically significant anxiety and depression in patients attending the hospital. 3 It contains 14 questionnaire items and consists of two subclasses, anxiety and depression. 4 The study aimed to evaluate any association of anxiety and depression in the healing of chronic leg ulcers.
2. MATERIALS AND METHODS
It was a prospective cohort study conducted at All India Institute of Medical Sciences Rishikesh from December 2017 to December 2019. The Institutional ethics committee approved the study protocol (148/IEC/IM/NF/2017/AIIMS, Rishikesh). Informed consent was taken from all the participants included in the study. Inclusion criteria were all the adult patients with leg ulcers for more than three months. Exclusion criteria were patients with acute leg ulcers and those who did not wish to participate in the study. Considering the reference value of the Pearson coefficient of 0.85 in the previous study (psychological factors and delayed healing of chronic wounds) at confidence interval (CI) 95% (alpha 0.5 and power 80% at CI 95%, the sample size calculated came as 125. A total of 125 consecutive patients with chronic leg ulcers who reported to the surgical outpatient department (OPD) and fulfilled the inclusion criteria were included in the study. The initial assessment of the wound was done concerning the history and clinical examination, and the patient was investigated to find the aetiology of the ulcer. Haematological investigations were done like complete blood count (CBC), kidney function test, blood sugar, and Glycosylated haemoglobin (HbA1C‐in diabetic patients). Doppler Ultrasound study of the arterial and venous system of the lower limb was done in patients with diabetes, peripheral arterial disease, and varicose vein, respectively. Appropriate treatment was started that included debridement of the wound, antibiotics according to wound culture and sensitivity, insulin for diabetic patients, and multilayer bandages for venous ulcers.
All the patients were provided with a HADS questionnaire for the initial assessment of anxiety and depression scale (Table 1). Regular clinical assessment of the wound was done on subsequent visits for 90 days to evaluate the ulcer's extent, and signs of healing of the wound noted on a spreadsheet. Data were analysed at the end of 30 and 90 days. Healing of the ulcer anytime during this period or non‐healing of ulcer despite appropriate treatment for 90 days was the endpoint of the study. To measure the extent of the ulcer wound, a perimeter was taken, which is the largest diameter of the wound and diameter at the right angle to the largest one. HADS score has three scales 0‐7 = Normal, 8‐10 = Borderline abnormal (borderline case), and 11‐21 = Abnormal (case). The total HADS score of individual patients was analysed with the status of leg ulcers.
TABLE 1.
| D | A | D | A | ||
|---|---|---|---|---|---|
| I still enjoy the things I used to enjoy: | I get a sort of frightened feeling like “butterflies” in the stomach | ||||
| 1 | Not quite so much | 1 | Occasionally | ||
| 2 | Only a little | 2 | Quite often | ||
| 3 | Hardly at all | 3 | Very often | ||
| I get a sort of frightened feeling as if something awful is about to happen | I have lost interest in my appearance | ||||
| 3 | Very definitely and quite badly | 3 | Definitely | ||
| 2 | Yes, but not too badly | 2 | I do not take as much care as I should | ||
| 1 | A little, but it does not worry me | 1 | I may not take quite as much care | ||
| 0 | Not at all | 0 | I take just as much care as ever | ||
| I can laugh and see the funny side of things | I feel restless as I have to be on the move | ||||
| 0 | As much as I always could | 3 | Very much indeed | ||
| 1 | Not quite so much now | 2 | Quite a lot | ||
| 2 | Definitely not so much now | 1 | Not very much | ||
| 3 | Not at all | 0 | Not at all | ||
| Worrying thoughts go through my mind | I look forward with enjoyment to things | ||||
| 3 | A great deal of the time | 0 | As much as I ever did | ||
| 2 | A lot of the time | 1 | Rather less than I used to | ||
| 1 | From time to time, but not too often | 2 | Definitely less than I used to | ||
| 0 | Only occasionally | 3 | Hardly at all | ||
| I feel tense or “wound up” | I feel as if I am slowed down | ||||
| 3 | Most of the time | 3 | Nearly all the time | ||
| 2 | A lot of the time | 2 | Very often | ||
| 1 | From time to time, occasionally | 1 | Sometimes | ||
| 0 | Not at all | 0 | Not at all | ||
| I feel cheerful | I get sudden feelings of panic | ||||
| 3 | Not at all | 3 | Very often indeed | ||
| 2 | Not often | 2 | Quite often | ||
| 1 | Sometimes | 1 | Not very often | ||
| 0 | Most of the time | 0 | Not at all | ||
| I can sit at ease and feel relaxed | I can enjoy a good book or radio or TV programme | ||||
| 0 | Definitely | 0 | Often | ||
| 1 | Usually | 1 | Sometimes | ||
| 2 | Not Often | 2 | Not often | ||
| 3 | Not at all | 3 | Very seldom |
Note: Hospital anxiety and depression scale (HADS): contains 14 questionnaire items and consists of two subclasses, anxiety (A) and depression (D) Each subclass has three types of scores.
2.1. Statistical analysis
Statistical analyses were performed using R Statistical software version 3.6.2 (R Core Team [2019], Methodology Reference Indicator codes: CSI 019, WAT 002, R foundation for statistical computing, Vienna, Austria). A binary logistic regression was conducted to examine whether disease (etiological types of ulcer) and HADS score had a significant effect on the odds of observing the non‐healing category of ulcer status in 30 days. The reference category for ulcer status in 30 days was healed.
3. RESULTS
A total of 125 consecutive patients with chronic leg ulcers who fulfilled the inclusion criteria were enrolled. The authors encountered mainly venous, ischaemic, and diabetic ulcers. Out of 125, 99 (79%) cases were males and 26 (21%) females. Diabetic (neuropathic) and ischaemic leg ulcers shared an equal proportion of 38, whereas venous ulcers were 49 in number (Table 2).
TABLE 2.
Demography of chronic leg ulcer
| Diseases | Male | Female | Total (n = 125) |
|---|---|---|---|
| Venous ulcer (VU) | 38 | 11 | 49 |
| Diabetic ulcer (DU) | 32 | 6 | 38 |
| Ischaemic ulcer (IU) | 29 | 9 | 38 |
| Total | 99 | 26 | 125 |
The model was evaluated based on an alpha of .05. The overall model was significant, χ2(4) = 108.63, P < .001, suggesting that disease and HADS score had a significant effect on the odds of observing the non‐healing of ulcer in 30 days. McFadden's R‐squared value was calculated to examine the model fit, where values greater than two are indicative of models with excellent fit. The McFadden R‐squared value calculated for this model was 0.63 (Table 3).
TABLE 3.
Summary of Regression model
| Dependent: ulcer status in 30 days | Healed | Non‐healing | Total | P | |
|---|---|---|---|---|---|
| Disease | D U | 14 (21.2) | 24 (40.7) | 38 (30.4) | .038 |
| I U | 25 (37.9) | 13 (22.0) | 38 (30.4) | ||
| V U | 27 (40.9) | 22 (37.3) | 49 (39.2) | ||
| HADS score | Mean (SD) | 11.6 (3.9) | 15.8 (2.0) | 13.6 (3.8) | <.001 |
| Ulcer size (cm2) | Mean (SD) | 5.2 (3.1) | 18.6 (17.9) | 11.5 (14.1) | <.001 |
Abbreviations: DU, diabetic ulcer; IU, ischaemic ulcer; VU, venous ulcer.
The regression coefficient for ischaemic ulcers was not significant. B = 1.71, OR = 5.54, P = .076, indicating that ischaemic ulcers, did not significantly affect the odds of observing the non‐healing of ulcer in 30 days (Table 4).
TABLE 4.
Regression model with odds ratio
| Dependent: ulcer status in 30 days | Healed | Non‐healing | OR (univariable) | OR (multivariable) | |
|---|---|---|---|---|---|
| Disease | D U | 14 (36.8) | 24 (63.2) | ‐ | ‐ |
| I U | 25 (65.8) | 13 (34.2) | 0.30 (0.12‐0.76, P = .013) | 5.54 (0.92‐43.15, P = .076) | |
| V U | 27 (55.1) | 22 (44.9) | 0.48 (0.20‐1.12, P = .093) | 11.93 (2.11‐95.99, P = .010) | |
| HADS score | Mean (SD) | 11.6 (3.9) | 15.8 (2.0) | 1.73 (1.45‐2.14, P < .001) | 1.63 (1.22‐2.29, P = .002) |
Note: MODEL FIT: χ2(4) = 108.63, P = <.001 Pseudo‐R 2 = 0.63; Number in data frame = 125, Number in model = 125, Missing = 0; AIC = 74.3, C‐statistic = 0.961, H&L = Chi‐sq(8) 7.68 (P = .465).
The venous ulcer's regression coefficient was significant, B = 2.48, OR = 11.93, P = .010, indicating that if the disease was a venous ulcer, the odds of observing the non‐healing of ulcer in 30 days will increase by approximately 11.93 times (Table 4).
The regression coefficient for the HADS score was significant, B = 0.49, OR = 1.63, P = .002, indicating that for a one‐unit increase in HADS score, the odds of observing the non‐healing of ulcer in 30 days would increase by approximately 63% (Table 4).
The receiver operating characteristic (ROC) curve was constructed to find the HADS score, predicting the non‐healing of ulcers (Figure 1). Ulcer status (Non‐healing vs healed) after 30 days of appropriate treatment was analysed using the HADS cutoff score (Table 5). The area under the ROC curve (AUROC) for HADS score predicting ulcer status after 30 Days for non‐healing vs healed was 0.848 (95% CI: 0.781–0.914) demonstrating good diagnostic performance. It was statistically significant (P = <.001) (Figure 1).
FIGURE 1.
ROC curve analysis showing diagnostic performance of HADS score in predicting ulcer status (30 days): Non‐healing vs Healed (n = 125) with cutoff value 14
TABLE 5.
HADS score for predicting ulcer status in 30 days: non‐healing vs healed
| Variable | Category(s) suggesting outcome present | Category(s) suggesting outcome absent | Total P | True P | True N | False P | False N |
|---|---|---|---|---|---|---|---|
| Ulcer status (30 days) | Non‐healing | Healed | 59 (47.2%) | ‐ | ‐ | ‐ | ‐ |
| HADS score (Cut off: 14 by ROC) | > = 14 | <14 | 68 (54.4%) | 49 (39%) | 47 (38%) | 19 (15%) | 10 (8%) |
| HADS score (Cut off: > = 11) | > = 11 | <11 | 111 (88.8%) | 59 (47%) | 14 (11%) | 52 (42%) | 0 (0%) |
Abbreviations: P, positive; N, negative.
At a cutoff of HADS score ≥ 14, it predicted the non‐healing of ulcer after 30 days with a sensitivity of 83% and a specificity of 71% (Figure 1), and the P‐value was <.001, which was significant. The odds ratio (95% CI) for non‐healing ulcers after 30 days when the HADS score is ≥14 was 11.29 (4.87‐26.16). The relative risk (95% CI) for non‐healing ulcers after 30 days when the HADS score is ≥14 was 3.73 (2.28‐6.43) (Figure 1).
Ulcer status (Non‐healing vs healed) was analysed with all the parameters after 30 and 90 days of appropriate treatment (Tables 6 and 7). The disease, HADS score, and HADS category were significantly associated (P < .05) with the ulcer status (30 and 90 days).
TABLE 6.
Association between ulcer status (30 days) and all parameters
| All parameters | Ulcer status (30 days) | P‐value | |
|---|---|---|---|
| Healed (n = 66) | Non‐healing (n = 59) | ||
| Gender | .9041 | ||
| Male | 52 (78.8%) | 47 (79.7%) | |
| Female | 14 (21.2%) | 12 (20.3%) | |
| Disease a | .0381 | ||
| D U | 14 (21.2%) | 24 (40.7%) | |
| I U | 25 (37.9%) | 13 (22.0%) | |
| V U | 27 (40.9%) | 22 (37.3%) | |
| HADS score a | 11.62 ± 3.88 | 15.76 ± 2.05 | <.0012 |
| HADS Category a | <.0011 | ||
| <11 | 14 (21.2%) | 0 (0.0%) | |
| ≥11 | 52 (78.8%) | 59 (100.0%) | |
Note: 1: Chi‐squared test, 2: Wilcoxon‐Mann–Whitney U Test.
Significant at P < .05.
TABLE 7.
Association between ulcer status (90 days) and all parameters
| All parameters | Ulcer status (90 days) | P‐value | |
|---|---|---|---|
| Healed (n = 4) | Non‐healing (n = 50) | ||
| Gender | .5291 | ||
| Male | 3 (75.0%) | 42 (84.0%) | |
| Female | 1 (25.0%) | 8 (16.0%) | |
| Disease a | .0291 | ||
| D U | 2 (50.0%) | 24 (48.0%) | |
| I U | 2 (50.0%) | 4 (8.0%) | |
| V U | 0 (0.0%) | 22 (44.0%) | |
| HADS score a | 13.50 ± 1.91 | 15.74 ± 2.08 | .0422 |
| HADS Category | 1.0003 | ||
| <11 | 0 (0.0%) | 0 (0.0%) | |
| ≥11 | 4 (100.0%) | 50 (100.0%) | |
Note: 1: Fisher's exact test, 2: Wilcoxon‐Mann–Whitney U Test, 3: Chi‐Squared Test.
Significant at P < .05.
We further analysed the positive predictive value (PPV) and negative predictive value (NPV) of the HADS score. The diagnostic accuracy for predicting non‐healing of the ulcer was nearly 77% when the HADS score was 14 whereas it was 58% when the HADS score was 11 (Table 8).
TABLE 8.
Primary diagnostic parameters
| Variable | Sensitivity | Specificity | PPV | NPV | Diagnostic accuracy |
|---|---|---|---|---|---|
| HADS score (Cut off: 14 by ROC) | 83.1% (71‐92) | 71.2% (59‐82) | 72.1% (60‐82) | 82.5% (70‐91) | 76.8% (68‐84) |
| HADS score (Cut off: > = 11) | 100.0% (94‐100) | 21.2% (12‐33) | 53.2% (43‐63) | 100.0% (77‐100) | 58.4% (49‐67) |
4. DISCUSSION
The prevalence of chronic wounds in the Indian population is approximately 4.5/1000, whereas the incidence of acute wounds is more than double at 10.5/1000 population. 5 Leg ulcers have multifactorial aetiology. It is difficult to divide its aetiology into arterial or venous diseases. 6 , 7 Mixed arterial and venous aetiology is common in chronic leg ulcers. 1 , 6 , 8 Treatment of such ulcers is also difficult. There are definite guidelines for immediate intervention in the management of non‐healing ulcers due to critical limb ischaemia. However, there is no uniform agreement to support the surgical treatment of varicose veins that cause a venous ulcer. 9 Diabetic ulcers also have ischaemia along with neuropathy.
The phases of wound healing are inflammatory, proliferative, and maturation or remodelling. These three phases are continuous, and they can overlap and do not always occur in an orderly fashion. 10 Wound healing may be retarded by age, diabetes, smoking, immunosuppression, and poor nutrition. Psychological factors and the endocrine and immune systems play an essential role in wound healing, 11 , 12 , 13 thereby causing delayed wound healing and recurrence of chronic wounds. 14 , 15 Present study showed a strong association of anxiety and depression with wound healing. Depression is associated with impairment of both cellular and humoral immunity. 16 Stress is a known factor for the secretion of pro‐inflammatory cytokines at the wound site, that delays wound healing. 16 Stotts and Wipke‐Tevis research shows the association of psychophysiological stress and delayed wound healing. 17 Palmer too pointed out that psychological and psychosocial problems affect wound healing. 18 Depressed individuals are self‐neglected and have disturbed sleep and poor appetite. Disturbed sleep interferes with the immune system by disrupting the role of lymphocytes and macrophages. Activated macrophages secrete the chemokines (IL‐1 and IL‐2). IL‐1 is essential for routine wound healing. These disorders in depressed people lead to delayed wound healing. 19 , 20 , 21 There is malnutrition because of poor appetite, which leads to a deficiency of vitamins and trace elements that interfere with wound healing in a person with anxiety and depression.
In 2015 Dalgart et al. in a multicenter study observed the highest rate of depression in leg ulcers than other skin diseases. 22 In one study, 30% of all patients with non‐healing chronic leg ulcers suffered from depression three times higher than those with leg ulcers without healing problems. 23 , 24 , 25 , 26 Iversen et al. observed the three‐fold development of non‐healing ulcers when the score was >11. 27 In our study, 89% (111) of patients had a HADS score of more than or equal to 11 and 47% (59) were true positive for non‐healing ulcers after one month of appropriate treatment, which is higher than the previous studies. Our study demonstrated that the sensitivity and specificity of the HADS score of >11 for detecting non‐healing ulcers is 100% and 21.2%, whereas it is 83.1% and 71.2%, respectively, when HADS score is >14. The present study showed a diagnostic accuracy of 76.8% with the HADS score of 14, whereas it was 58.4% when the score was 11.
In 2016 Zhou K et al. observed that the ulcer's aetiology was independent of depressive symptoms. 25 They also observed the presence of pain, wound discharge, foul smell, and decreased mobility as the cause of increased HADS score. The results of our study are in concordance with the previous studies.
5. CONCLUSION
The periodic assessment of wound healing in chronic leg ulcers is one of the essential principles in wound management. Progress of wound healing must be documented to assess the effectiveness of treatment and any factor that may be associated with delayed wound healing. Psychosocial factors retard the process of wound healing by their action on the immune system, hence a simultaneous psychological analysis should be done alongside local treatment to get better results in chronic wounds.
CONFLICT OF INTEREST
None declared.
ETHICS STATEMENT
The study was approved by the Institutional Ethics Committee.
ACKNOWLEDGEMENTS
None.
Kumar N, Huda F, Mani R, et al. Role of hospital anxiety and depression on the healing of chronic leg ulcer: A prospective study. Int Wound J. 2020;17:1941–1947. 10.1111/iwj.13485
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.