Abstract
Diabetic foot ulcer (DFU) exerts a heavy physical and emotional burden on patients with diabetes mellitus. The purpose of the present study was to explore the impact of anxiety and perceived social support on depression of DFU patients well as patients' characteristics associated with depression. The sample of the study consisted of 180 DFU patients. Data collected by the completion of “Self‐rating Depression/Anxiety Scale‐ Zung” (SDS/SAS) and the Multidimensional Scale of Perceived Social Support (MSPSS). Patients had moderate levels of anxiety and depression (median: 36, 42, respectively) and high levels of perceived social support from their significant ones, their family and friends (median: 24, 24, 17, respectively). After multiple regression factors that were found to have an impact on depression after taking into account all other factors, were patient's age of above 70 years, patient's anxiety and the social support they received from their significant ones. More specifically, patients aged above 70 years had 9.51 points higher depression than patients aged <50 years of age (β = 9.51, 95% CI: [0.76, 18.25], P = .034). Moreover, one point increase in patient's anxiety score indicated an increase of 0.71 points in patient's depression (β = 0.71, 95% CI: [0.43, 1.00], P = .001). On the contrary, one point increase in patient's social support from their significant ones indicated a decrease of 1.52 points in patient's depression (β = −1.52, 95% CI: [−0.25, −2.79], P = .020). Clinically, a better understanding of factors having an impact on depression on DFU may provide an essential in planning cost effective interventions.
Keywords: depression/anxiety, diabetic foot ulcer, perceived social support, zung scale
1. INTRODUCTION
Diabetic foot ulcer (DFU) is a common complication of diabetes mellitus, associated with amputation and life‐threatening complications. According to estimates, 15% of patients may experience a DFU through their life 1 and face with significant risk of amputation, irrespective of socioeconomic group and geographical region.2, 3, 4 Furthermore, approximately two‐thirds of DFU will heal within 6 months while in 60% of individuals, the ulceration may reoccur within 12 months. 5 Additionally, DFU management exerts directly a heavy economic burden on the health care system of every country, globally, while indirectly, the cost mainly involves loss in productivity attributed to disability and premature mortality.6, 7
DFUs are also associated with intangible costs, such as pain, suffering, grief, and psychological burden, mainly anxiety and depression, which adversely affect patients' quality of life. 6 Furthermore, the emotional burden among DFU is attributed to several reasons such as physical difficulties and practical issues in daily life, dependency on others, risk of amputation, increased health care needs, feelings of fear, helplessness, frustration, and loss of mobility associated with ulceration severity.7, 8, 9, 10, 11
Depression, seems to be higher individuals with diabetes mellitus, increases the risk of diabetic complications, is associated with delay in wound healing, and has a threefold increased risk of mortality within 18 months after first foot ulcer. 5 It is noteworthy that depression may occur as a response to DFU foot ulceration while is also associated with increased risk of developing DFU compared with people with diabetes and no depression.5, 8
Social support is defined as the help from others that an individual can feel, comprehend, notice, or accept. This environmental resource constitutes a protective factor for individuals experiencing stressful life events 12 and also promotes a person's physical and mental health. 13 For instance, a supportive network mitigates the likelihood of depression by encouraging patients to resist to negative emotions or helping patients to relieve an already established depression through improving self‐esteem. Significantly, more social support may enhance patients' coping capacities and problem‐solving strategies, may alleviate the stress of living with a chronic illness, thus minimising the intensity of depression. 12 Perceived social support is also positively associated with improved self‐management among individuals with DFU. 14
Comorbid anxiety is common in patients with depression, complicating the clinical presentation of depression. Additionally, there is an overlap between depression and anxiety symptoms by determining whether or not an individual with depression simultaneously meets criteria for an anxiety disorder. 15
To the best of our knowledge, data exploring the impact of anxiety and perceived social support on depression among DFU patients are limited. Thus, the aim of this cross‐sectional study was to explore the levels of depression, anxiety, and perceived social support in DFU, the factors associated with depression, and the impact of anxiety and perceived social support on depression.
2. MATERIALS AND METHODS
2.1. Study population
In the present cross‐sectional study, 180 DFU patients were enrolled attending follow‐up visits in outpatient clinic of a public hospital in Attica. It was a convenient sample. The study included patients during the period March 2018 to December 2018.
Criteria for inclusion of patients in the study were the following: (a) adult patients with type 2 DM attending diabetic follow‐up visits at public hospital in Athens during the study period and (b) the ability to write and read the Greek language fluently. The exclusion criteria were patients (a) with a history of mental illness, (b) with traumatic ulcer, and (c) who were severely ill and unable to communicate throughout the study period. Patients who met those criteria were informed by the researcher orally for the purpose of this study.
In the present study, there was no intervention or control group since this research merely recorded whether patients experienced anxiety, depression, social support, and the impact of these variables on depression. The interview lasted approximately 15 minutes and took place for all participants while waiting for their clinic follow‐up.
2.2. Ethical considerations
The study was approved by the Medical Research Ethics Committee of the hospital that this study took part in, and it was conducted in accordance with the Declaration of Helsinki (1989) of the World Medical Association. All patients participated in the study voluntarily and had their anonymity preserved. Written informed consent was obtained from all patients being interviewed.
2.3. Data variables
Data collection was performed by the method of interview using the following: (a) The “Self‐rating Anxiety/Depression Scale (SAS/SDS)—Zung”16, 17 and (b) the Multidimensional Scale of Perceived Social Support questionnaire (MSPSS). 18
Additionally, data collected for each patient included the following: sociodemographic characteristics, clinical characteristics, and other patients' self‐reported characteristics.
The severity of foot ulcer was classified according to the Wagner wound classification system, as follows 19 :
Grade 0: intact skin.
Grade 1: superficial ulcer of skin or subcutaneous tissue.
Grade 2: ulcers extend into tendon, bone, or capsule.
Grade 3: deep ulcer with osteomyelitis, or abscess.
Grade 4: partial foot gangrene.
Grade 5: whole foot gangrene.
2.4. Measuring anxiety/depression
The “Self‐rating Anxiety/Depression Scale (SAS/SDS)—Zung” scale was used to assess anxiety and depression in patients with heart failure. The SAS/SDS scale consists of 20 questions for anxiety and 20 for depression that evaluate how respondents felt during the previous week. Respondents have the ability to answer each question on a four‐point Likert type scale. In five questions, it is first necessary to reverse the scores. The scores attributed to the questions are summed up leading to a final score ranging from 20 to 80. Higher scores indicate higher levels of anxiety/depression.16, 17
2.5. Measuring perceived social support
To evaluate perceived social support, we used the Multidimensional Scale of Perceived Social Support (MSPSS) questionnaire, which has been translated and culturally adapted to Greek standards. The questionnaire assesses three dimensions of perceived social support, and the questions of each are expressed via level of support rated on a 7‐point Likert scale from 1 to 7. In order to calculate the final score of each dimension of the questionnaire, scores of questions corresponding to each dimension are summed and divided by the number of questions per dimension. Higher scores reflect higher support. The scale has reported Cronbach α = 0.80 and intraclass correlation coefficient (ICC) = 0.89. 18
2.6. Statistical analysis
Categorical variables are presented with absolute and relative frequencies (percentages), and quantitative variables are presented by median and interquartile range since they did not follow the normal distribution (tested with histogram, quantile‐quantile plot, and Kolmogorov‐Smirnov test). To test the existence of association between patient's characteristics, anxiety, support, and depression score, the Kruskal‐Wallis or the Mann–Whitney test was performed, as well as the Spearman's rho correlation coefficient. Multiple regression was performed in order to assess the effect of patient's characteristics, anxiety, and support on their depression. The level of statistical significance was set to a = 5%. The analysis was performed using the statistical package SPSS, version 25 (SPSS Inc, Chicago, Il).
3. RESULTS
3.1. Sample description
Table 1 describes patient's demographic characteristics. Men accounted for 59.4% of the sample, while 54.4% of the sample was above 60 years of age, 63.9% were married, 41.6% had primary school education, 49.4% were pensioners, 60% was living in Attica, and 73% had more than two children.
TABLE 1.
Patients' demographics (Ν = 180)
| Ν (%) | Ν (%) | ||
|---|---|---|---|
| Gender | Job | ||
| Male | 107 (59.4%) | Unemployed | 6 (3.3%) |
| Female | 73 (40.6%) | Civil servant | 12 (6.7%) |
| Age (years) | Employee | 22 (12.2%) | |
| <40 | 6 (3.3%) | Freelancer | 14 (7.8%) |
| 41‐50 | 17 (9.4%) | Household | 35 (19.4%) |
| 51‐60 | 59 (32.8%) | Pensioner | 89 (49.4%) |
| 61‐70 | 36 (20.0%) | Residency | |
| >70 | 62 (34.4%) | Attica | 108 (60.0%) |
| Status | Capital City | 42 (23.3%) | |
| Married | 115 (63.9%) | Small Town | 30 (16.6%) |
| Single | 7 (3.9%) | No of children | |
| Divorced | 20 (11.1%) | 0 | 9 (5.1%) |
| Widowed | 37 (20.6%) | 1 | 39 (21.9%) |
| Living together | 1 (0.6%) | 2 | 115 (64.6%) |
| Education | >2 | 15 (8.4%) | |
| Primary school | 74 (41.6%) | ||
| High school | 73 (41.0%) | ||
| University | 31 (17.4%) |
Tables 2, 3, 4 describe the clinical and other self‐reported characteristics. In detail, regarding clinical characteristics, 57.8% were diagnosed by chance, 66.9% suffered from another disease, 58% received insulin subcutaneous, 27.8% were “very well” informed about their health problem, and family environment was “well” informed in 52% of participants. The median age of diagnosis was 50 years, the median BMI was 26.5 kg/m2 while 27.6% were current smokers and 50% of the patients had diabetic ulcer for more than 1 year. According to the Wagner ulcer classification, 31.6% of participants were of ulcer grade 2. In terms of adherence, 74.4% measured blood glucose on a daily basis and 55.6% measured their HbA1c every 4‐6 months. 24.4% were following very closely the periodic follow‐up, 11.1% the proposed diet, and 58.1% the medication. The majority of patients had very good relations with nursing and medical staff (50.3% and 68%, respectively).
TABLE 2.
Patient's clinical characteristics (Ν = 180)
| Ν (%) | |
|---|---|
| Diagnosis | |
| By chance | 104 (57.8%) |
| Due to other problem | 37 (20.6%) |
| After encouragement of others | 29 (16.1%) |
| My decision to seek for care | 10 (5.5%) |
| Other disease | |
| No | 59 (33.1%) |
| Yes | 119 (66.9%) |
| Treatment of diabetes mellitus | |
| Antidiabetic tablets | 74 (42.0%) |
| Insulin subcutaneous | 102 (58.0%) |
| Informed about the state of health | |
| Very | 50 (27.8%) |
| Enough | 90 (50.0%) |
| A little | 38 (21.1%) |
| Not at all | 2 (1.1%) |
| Is family environment well informed? | |
| Very | 30 (16.8%) |
| Enough | 93 (52.0%) |
| A little | 47 (26.3%) |
| Not at all | 9 (5.0%) |
| Smoking | |
| No | 55 (72.4%) |
| Yes | 21 (27.6%) |
| Median (IQR) | |
|---|---|
| Age of diagnosis | 50 (40‐60) |
| BMI | 26.5 (24‐30) |
| Years with diabetic foot ulcer | 1 (0.6–1) |
Abbreviations: BMI, body mass index; IQR, interquartile range.
TABLE 3.
Patients' Wagner Classification s (Ν = 180)
| Wagner ulcer classification | Ν (%) |
|---|---|
| WAGNER | |
| Grade 1: superficial ulcer of skin or subcutaneous tissue | 53 (29.4%) |
| Grade 2: ulcers extend into tendon, bone, or capsule | 57 (31.6%) |
| Grade 3: deep ulcer with osteomyelitis, or abscess | 32 (17.8%) |
| Grade 4: partial foot gangrene | 25 (13.9%) |
| Grade 5: whole foot gangrene | 13 (7.2%) |
TABLE 4.
Patients' adherence characteristics and other self reports (Ν = 180)
| Ν (%) | |
|---|---|
| Adherence to medication | |
| Very | 104 (58.1%) |
| Enough | 68 (38.0%) |
| A little | 7 (3.9%) |
| Not at all | 0 (0.0%) |
| Measure glucose on a daily basis | |
| No | 46 (25.6%) |
| Yes | 134 (74.4%) |
| How often do you measure HbA1c | |
| 2‐3 months | 40 (22.2%) |
| 4‐6 months | 100 (55.6%) |
| 7‐10 months | 23 (12.8%) |
| 11‐12 months | 17 (9.4%) |
| Adherence to periodic follow‐up | |
| Very | 44 (24.4%) |
| Enough | 105 (58.3%) |
| A little | 28 (15.6%) |
| Not at all | 3 (1.7%) |
| Adherence to the proposed diet | |
| Very | 20 (11.1%) |
| Enough | 82 (45.6%) |
| A little | 71 (39.4%) |
| Not at all | 7 (3.9%) |
| Relations with nursing staff | |
| Very good | 90 (50.3%) |
| Good | 71 (39.7%) |
| Moderate | 18 (10.1%) |
| Relations with medical staff | |
| Very good | 51 (68.0%) |
| Good | 24 (32.0%) |
3.2. Anxiety/depression and perceived social support
Table 5 presents the distribution of scores of anxiety, depression, and perceived social support. It is observed that patients had moderate levels of anxiety and depression. More in detail, half the patients scored above 36 and 42, respectively, and 25% of them scored above 46 and 51, respectively.
TABLE 5.
Social support, anxiety/depression (Ν = 180)
| Median (IQR) | |
|---|---|
| Zung | |
| Anxiety (range: 20‐80) | 39 (34‐46) |
| Depression (range: 20‐80) | 42 (35‐51) |
| Support from: | |
| Significant ones (range: 4‐28) | 24 (20‐27) |
| Family (range: 4‐28) | 24 (21‐26) |
| Friends (range: 4‐28) | 17 (14.5‐20) |
Abbreviations: IQR, interquartile range.
In terms of perceived social support, it is noted that DFU patients perceived high levels of social support. More in detail, within the possible range of scores (4‐10, 12‐16, 18‐23, 25‐31), it is noted that at least 50% of the patients scored over 24, 24, and 17 (median) in support from their significant ones, their family, and friends, respectively. In addition, 25% of the patients had scores above 27, 26, and 20, respectively.
3.3. Factors associated with depression
Table 6 presents the factors that were statistically significantly associated with depression.
TABLE 6.
Association between patients' characteristics, anxiety, support, and depression of DFU patients (Ν = 180)
| Median (IQR) | P value | Median (IQR) | P value | ||
|---|---|---|---|---|---|
| Demographics | |||||
| Age (years) | .001 | Education | .001 | ||
| <50 | 36 (30‐42) | Primary School | 45.5 (40‐54) | ||
| 51‐60 | 41 (32‐46) | High School | 41 (33‐49) | ||
| 61‐70 | 46 (41‐53.5) | University | 39 (32‐46) | ||
| >70 | 47 (36‐54) | Job | .001 | ||
| Status | .019 | Unemployed/household | 42 (37‐54) | ||
| Married/living together | 41.5 (32‐48.5) | Employee | 36.5 (31‐41,5) | ||
| Single/divorced | 45 (37.5‐52.5) | Pensioner | 46 (41‐53) | ||
| Clinical characteristics | |||||
| Other disease | .003 | WAGNER | .006 | ||
| No | 41 (32‐49) | Grade 1 | 41 (32‐48) | ||
| Yes | 44 (37‐52) | Grade 2 | 41 (37‐47) | ||
| Informed about state of health | .001 | Grade 3 | 45 (35.5‐54) | ||
| Very | 38.5 (31‐46) | Grade 4 | 48 (41‐52) | ||
| Enough | 42 (36‐50) | Grade 4 | 50 (44‐55) | ||
| A little/not at all | 51 (41.5‐54.5) | Spearman's rho | P value | ||
| Smoking | .027 | Age of diagnosis | 0.272 | 0.001 | |
| No | 41 (33‐46) | Zung | Spearman's rho | P value | |
| Yes | 49 (39‐55) | Anxiety | 0.746 | .001 | |
| Follow strictly the periodic check | .009 | Support from: | |||
| Very | 40 (30.5‐45.5) | Significant ones | −0.279 | .001 | |
| Enough | 43 (36‐52) | Family | −0.345 | .001 | |
| A little/not at all | 45 (37‐54) | Friends | −0.425 | .001 | |
| Follow strictly the proposed diet | .001 | ||||
| Very | 39 (34.5‐43.5) | ||||
| Enough | 40.5 (32‐48) | ||||
| A little/not at all | 47 (38‐54) |
Note: Values are significant at the .05 probability level.
Abbreviation: IQR, interquartile range.
A statistically significant association was observed between patient's depression and age (P = .001), marital status (P = .019), education (P = .001), and job (P = .001).
More specifically, patients older than 60 years of age felt more depression (median for 61‐70 years of age: 46; and median for >70 years of age: 47) than younger patients (median for <50 years of age: 36; and median for 51‐60 years of age: 41). Single/divorced patients felt more depression (median 45) than married patients (median 41.5). Likewise, patients with primary school education felt more depression (median 45.5) than patients with high school or university education (median 41 and 39, respectively). Also, pensioners felt more depression (median 46) than unemployed patients (median 42) or employees (median 36.5).
Regarding clinical characteristics, depression was statistically significantly associated with other disease (P = .003), the degree of information (P = .001), how strictly patients adhered to their periodic check and the proposed diet (P = .009, P = .001, respectively), the ulcer Wagner classification (P = .006), whether patients were smokers (P = .027), and the age of diagnosis (P = .001). More specifically, patients who had other disease also had higher levels of depression (median 44) than those who did not (median 41). In addition, higher levels of depression were experienced by patients who were “a little or not at all” informed about their health problem (median 51), those who followed “a little or not at all” their periodic check and diet (median 45, 47, respectively), those who had grade 5 (median 50) or grade 4 (median 48) and those who were smoking (median 49). Moreover, the age of diagnosis was positively associated with depression (ρ = 0.272), indicating that the older a DFU patient was, the higher depression was facing.
Regarding anxiety, it was statistically significantly positively associated with depression as one would expect (ρ = 0.746, P = .001). The higher anxiety a patient was feeling, the higher depression also felt.
On the other hand, a statistically significantly negatively association was found between depression and support from significant ones (ρ = −0.279, P = .001), support from family (ρ = −0345, P = .001), and support from friends (ρ = −0.425, P = .001). The higher support a patient was feeling from their significant ones, family and friends, the lesser depression they felt.
3.4. Impact of factors on depression
Table 7 presents that multiple regression was performed in order to assess the effect of the abovementioned factors on patient's depression. Factors that were found to have an impact on depression after taking into account all other factors were patient's age of above 70 years, patient's anxiety, and the support they were feeling from their significant ones.
TABLE 7.
Impact of patients' characteristics and anxiety, support on depression
| β coefficient (95% CI) | P value | |
|---|---|---|
| Demographics | ||
| Age (years) | ||
| <50 | Ref. Cat. | |
| 51‐60 | 6.44 (−1.18, 14.05) | .095 |
| 61‐70 | 6.36 (−1.06, 13.79) | .091 |
| >70 | 9.51 (0.76, 18.25) | .034 |
| Zung | ||
| Anxiety | 0.71 (0.43, 1.00) | .001 |
| Support from: | ||
| Significant ones | −1.52 (−0.25, −2.79) | .020 |
| Family | 0.27 (−0.89, 1.44) | .640 |
| Friends | −0.41 (−1.24, 0.43) | .330 |
More specifically, patients aged above 70 years had 9.51 points higher depression than patients aged <50 years of age (β = 9.51, 95% CI: [0.76, 18.25], P = .034). Moreover, one point increase in patient's anxiety score indicated an increase of 0.71 points in patient's depression (β = 0.71, 95% CI: [0.43, 1.00], P = .001). On the contrary, one point increase in patient's support from their significant ones indicated a decrease of 1.52 points in patient's depression (β = −1.52, 95% CI: [−0.25, −2.79], P = .020). Values in bold are significant at the .05 probability level.
4. DISCUSSION
For our cross‐sectional study of 180 DFU patients who were receiving care in an outpatient wound clinic, we found that this sample perceived high levels of social support and experienced moderate anxiety and depression.
Participants who reported more depression were more likely to be older, single/divorced, of primary education, pensioners, to have some other disease, and be current smokers. A similar study conducted by Ahmad et al, 1 who explored 260 DFU patients in a diabetic foot clinic showed more prevalent depression in DFU patients <50 years of age, which contradicts the present finding that patients >60 years felt more depression. 1 The same researchers also showed that depression was positively associated with equal to or greater than three comorbid diseases and current smoker participants, which is in line with the present study.
Regardless of age or any other demographic characteristics, it is noteworthy that DFU patients face with multiple problems that may trigger or exacerbate depression, such as physical impairment, losses of family and friends, changes in roles, increased risks of recurrence, expensive treatment, diminished quality of life, prolonged hospitalisation, complex medical procedures, uncertainty, and fears about mortality.6, 20, 21
In the present study, single/divorced participants were more depressed. Patients with diabetes mellitus living alone are more likely to report feelings of depression, to utilise health services infrequently, to experience social isolation and less emotional and instrumental support, and to face with several problems related to self‐care, such as barriers to preparing meals, forgetting to take medicines. In particular, elderly patients with diabetes mellitus living alone need support for maintenance of functional independence. Strikingly more, when DFU patients are depressed, they need structured surveillance since they tend to delay in seeking for medical care or they fail to follow their monthly hospital appointments for monitoring and follow. This finding is of crucial importance in countries where there are insufficiently developed home care services systems.22, 23
Regarding educational background, patients with primary school education experienced more depression. Higher educational level seems to have a protective effect against anxiety and depression, which accumulates throughout life. 24 In turn, this becomes a beneficial option since individuals with a higher education level are more likely to obtain and comprehend information regarding care, and to achieve deeper understanding of the therapeutic regimen. Equally important linking pathway between higher education and low depression is through the development of self‐efficacy, which ultimately helps individuals to cope with life stressors. 24 The present finding may have implications for policy. For instance, if DFU individuals coming from disadvantaged backgrounds may gain from higher education with respect to reducing depression, then policies targeting this vulnerable group may be essential.
Another finding of this study concerned information, with participants being “a little or not at all” informed about their health to experience higher levels of depression. One of the main components in DFU management is acquisition of accurate and proper knowledge and afterwards, put this into practice. Providing patients with guidance and information, enables them to set realistic goals, to achieve significant improvements in foot care, including health behaviour change.25, 26, 27, 28 This result indicates that DFU patients are deprived of the benefits of information. Therefore, educational interventions should address psychological factors that often undermine comprehension of information and increase knowledge deficits about foot care. Health professionals should cooperate with patients and their families to ensure that they understand the context of this illness.
In terms of smoking, 27.6% of participants were current smokers. Cigarette smoking is associated with negative impacts on DFU since it decreases insulin sensitivity and increases glucose concentration while is a risk factor for poor wound healing and foot amputation. Smoking behaviour is increased when depression is established, thus leading to further damaging effects on DFU.29, 30
Analysis also showed that more depressed were the participants who followed “a little or not at all” their periodic check and diet. Depression consists an impede for regular physician control, thus posing a risk for the disruption of the treatment. Also, depressed patients may feel hopeless to adopt life style modifications and adopt adherence to therapy. Furthermore, symptoms of depression such as reduced energy, low motivation, and cognitive impairment adversely impact on individual's ability to self‐care.31, 32, 33, 34 Alternatively, non‐adherence to treatment may be a marker for depression, and consequently be an opportunity to screen for depression, which may be undiagnosed. 32
Self‐management requires assessment of psychological state including evaluation of perceptions about illness, expectations about disease management, and exploration of resources (financial, social, emotional). 20 Given that poor adherence is associated with higher rates of mortality in diabetes mellitus, then identifying DFU‐depressed patients at risk for treatment non‐adherence or failure to implement regular care is a matter of crucial importance.
Perhaps of greater concern is our finding that the higher the social support a patient perceived, the lesser the depression had. Social support has been linked to improved health outcomes in chronic illnesses. Perceived social support among depressed DFU individuals may enhance effectiveness of treatment, whereas DFU‐related functional decline may deteriorate depression. It is worth emphasising that the association between social support and depression may be bidirectional. More in detail, individuals that do not receive social support may experience depression while negative feelings aroused by stressful life events such as DFU may trigger social isolation. Social support and positive coping strategies seem to protect individuals from the devastating consequences of depression and lead to a better health control. Patients need to understand that DFU is not a restriction on social life but may be perceived as a new condition that requires adaptation.35, 36, 37
Last but not least, the higher anxiety a patient felt, the higher the depression also was. DFU patients are more likely to have depression and anxiety compared with diabetic patients without foot complications. Though depression and anxiety are two different medical conditions, their symptoms, causes, and treatments often overlap. Furthermore, each mental disorder (anxiety, depression) in physical illness may perpetuate the other. However, there are some distinguishing features. For instance, depressed individuals move slowly, and their reactions seem flattened whereas individuals with anxiety experience racing thoughts and tend to be more keyed up. A factor that could potentially protect patients with DF against severe depression is good adaptability to stress. 1
Understanding the relationship between anxiety and depression should prompt health professionals to provide beneficial care for DFU patients. 38
Perceived social support has an impact on depression but further research on DFU is necessary before firm conclusions are drawn. However, the significant association between support and depression has been shown in other chronic disease. For instance, a one‐point increase of the support from significant others, family and friends, it was found to reduce by 77%, 71%, and 56%, respectively, the probability of experiencing high levels of depression among 258 patients undergoing hemodialysis. 39
5. CONCLUSIONS
A deeper understanding of factors associated with depression will shed light on planning intervention strategies that address the needs of DFU patients.
For example, the finding the fact that the higher the support from significant ones, family and friends, the lesser the depression is may prompt health care professionals to incorporate social support as an integral part of therapeutic regimen. Meanwhile, the finding that the higher the anxiety, the higher the depression is may aware health care professionals to screen both these mental disorders.
6. LIMITATIONS OF THE STUDY
This study has some limitations. Convenience sampling is one of the limitations in this study. This method is not representative of all population with DFU living in Greece, thus limiting the generalisability of results. Other limitations are related to the study design, which was cross‐sectional and not longitudinal, thus not permitting investigation for causal relation between anxiety, depression, and social support.
The sample size was relatively small although many significant associations were observed. Moreover, subclinical symptoms of anxiety and depression were assessed using self‐report, and there was no information collected on clinical diagnosis. Finally, there was no next other measurement in time that would allow evaluation of possible changes in all dimensions under assessment (anxiety and perceived social support) that had an impact on depression. It would be interesting to monitor anxiety, depression, and perceived social support 12 or 24 months after baseline. However, it would also be of great interest to compare these variables among hospitalised DFU patients and DFU outpatients.
CONFLICT OF INTEREST
The authors declare no potential conflict of interest.
Polikandrioti M, Vasilopoulos G, Koutelekos I, et al. Depression in diabetic foot ulcer: Associated factors and the impact of perceived social support and anxiety on depression. Int Wound J. 2020;17:900–909. 10.1111/iwj.13348
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