Transcript The Incidence of Self-Reported Depressive

THE INCIDENCE OF SELF-REPORTED
DEPRESSIVE SYMPTOMATOLOGY IN
DIABETIC PATIENTS WITH LOWER
EXTREMITY WOUNDS UTILIZING THE
PHQ-9
Jean-Jacques Kassis, DPM
Gary Rothenberg, DPM, and Jasmaine Shelford
APHA 138th Annual Meeting and Expo 2010
Podiatric Health: Diabetic Foot Care
November 9, 2010
INTRODUCTION
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Substantial evidence has shown the
relationship between Diabetes and
Depression is bidirectional.
How does this affect your patients?
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Patients with diabetes and depression
have:
greater risk of morbid burdens
 more severe complications and associated
symptoms
 greater financial burden due to increased
work disability
 increased medical services used
(Lin, et al., 2010)
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DEPRESSION   DIABETES
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Depression is an incidental risk factor for the onset of
NIDDM
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Complications
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Hyperglycemia
Heart disease
Increased mortality
Negative effects manifest through hormonal, neuronal,
and/or immunity  insulin production is compromised
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The activation of the hypothalamic-pituitary-adrenal axis, the
sympathetic nervous system, proinflammatory, and
procoagulation responses may be the linking pathophysiolocal
explanation for disease progression in patients with insulin
dependent diabetes mellitus (IDDM) (Lin, et al., 2010)
DEPRESSION   DIABETES
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Patients with diabetes are twice as likely to be
depressed than the general population
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41.3% higher prevalence of depression vs.
16.7% of the general pop.(Peyrot et al.)
 47.1%
-pt depressed with multiple complications
 43.6 %-pt depressed with HgA1c
HOW SIGNIFICANT IS
A DIABETIC FOOT
ULCER?
DIABETIC FOOT ULCER (DFU)
• 85% of diabetes-related amputations
are preceded by a non healing foot
ulcer
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50- 70% of all LE amputations are related
to diabetes
• 3 - 8% of people with diabetes have a
foot ulcer
• Recurrence rate of new ulcers through
5-year follow-up= 50-70%
• Takes 11 to 14 weeks on average to
heal a DFU
DFU FINANCIAL IMPLICATIONS
47% increase risk of patients with diabetes
have a history of DFU vs. no history of DFU
 Mortality rates for patients with neuropathic
and ischemic DFUs are 45% and 55%
respectively
 DFU estimated annual cost of care= $15, 309
(1995)
 DFU and amputations were estimated to cost
$11 billion (2001)
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HOW DOES
DEPRESSION IMPACT
YOUR PATIENTS WITH
DIABETES?
ANSWERS!!!
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Non-adherence towards treatment
requirements
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Medications, offloading devices, frequency of topical
care, disrupted follow-up visits
Impaired progression through the cascade of
wound healing process at the cellular level
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Phases of wound healing
 Hemostasis-
0-2 days
 Inflammatory- 2-5 days
 Proliferative- 5-21 days
 Remodeling- 21 days- 2 years
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Pt with depression and diabetes will have a delayed
response to wound healing  poorer quality of life
WOUND HEALING
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SEVEN KEY QUESTIONS (to determine why
wounds don’t heal)
1.
2.
3.
4.
5.
6.
7.
Is the wound infected?
Is the wound ischemic?
Is there too much pressure?
Is the wound hypoxic?
Are there nutritional issues?
What is happening at the cellular level?
Is the patient compliant with the recommended
treatment?
DEPRESSION PREDICTS FIRST BUT NOT
RECURRENT DIABETIC FOOT ULCERS
GONZALEZ, J.S. ET AL. DIABETOLOGIA 2010;53:2241-2248.
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Purpose: To examine the
relationship between symptoms
of depression and the
development of diabetic foot
ulcers
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333 patients with DPN
71% male
Mean age 62 years
73% NIDDM
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Depression, diabetes
complications, and foot self-care
were assessed by self-report
Hospital Anxiety and Depression
Scale (HADS)
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Measures the absence of positive
effect and pleasure from daily task.
7 questions
Score of 8 is the optimal cutoff for
identifying depression.
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Results:
 Increase in depression score
(by one SD) was associated
with 48% increase in rate of
foot ulceration with no prior
foot ulcer
Conclusion:
 Suggests depression is
associated with increased risk
of first foot ulcer in DPN
patients
 Interventions that target
depression and foot self-care
before the development of
foot ulcers may successfully
prevent foot ulcerations
SCREENING TOOLS: Hospital Anxiety and Depression Scale (HADS)
SCREENING TOOLS: PHQ-9
PHQ-9 SCORING CARD FOR SEVERITY
DETERMINATION
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Scoring— add all checked boxes on
PHQ-9
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Quality values:
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Not at all = 0
Several days = 1
More than half the days = 2
Nearly every day = 3
Interpretation of Total Score
Total Score Depression Severity
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1-4 Minimal depression
5-9 Mild depression
10-14 Moderate depression
15-19 Moderately severe depression
20-27 Severe depression
OBJECTIVE: MIAMI VA STUDY
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PRIMARY: To investigate the incidence of selfreported depressive symptoms in diabetic patients
with current lower extremity complications
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Identify the average PHQ-9 score among patients with DM under
treatment for LE wounds and compare to patients with DM and no
history of LE wounds
SECONDARY: Introduce the PHQ-9 questionnaire to
wound care providers including podiatric
physicians as a simple, useful screening tool
STUDY PROTOCOL
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Target population: 100 Diabetic
patients enrolled in the Miami VA
Outpatient Diabetic Foot and
General Clinics
Inclusion and Exclusion criteria:
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Methods and materials:
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Inclusion:
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Pt with DM in the Miami VA with active
full thickness lesions to the LE
Pt with DM without LE wounds
Pt with DM without a previous history
of amputation
Exclusion
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Pt treated for wounds of non-diabetic
etiology
Pt who fail to complete all questions of
the PHQ-9 questionnaire
Pts consented
Subjects with and
without Diabetic LE
wounds completed the
PHQ-9
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Self-administration of
the questionnaire
Wound care and/or
other treatment plans
remained unchanged
Interim Data
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Evaluated 14 patients
aged 50-86 years old
(avg. 64 years old)
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8 patients with wounds
and 6 patients without
wounds
RESULTS
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Wounds (n=8)
Scores ranged from 0-16
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50% (4/8) of pt identified with
moderate-moderately severe
depression
No wounds (n=6) = control
Scores ranged from 1-24*
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*24- Pt flagged as High-risk
for suicide prior to enrollment
of study
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Dx with MDD with psychotic
features
33.3% of pt identified with
moderate to severe
depression
Wounds (n =8)
No wounds (n=6)
8.75
9.5
6.6 [Without outlier(24)]
Table 1. Mean score of PHQ-9 Score
•75 % (6/8) patients with DM and
wounds reported their depression
symptomatology renders it somewhat
difficult to do their work, function at
home and to cordially interact with
other people
•50% (3/6) patients with DM and no
wounds reported it very difficult to do
their work, function at home and to
cordially interact with other people as
opposed to 50% who find it not difficult
at all
CONCLUSION
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Currently there is no significant difference in
the incidence of self-reported depression in
patients who have diabetes and wounds and
those patients without wounds
 Depression
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is very common in both populations
PHQ-9 is an simple, quick screening tool for
depression in diabetic patients
 Results
indicate this tool is critical for all patients
with diabetes
REFERENCES
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PRESENTER DISCLOSURES
Jasmaine Shelford
(1)
The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
No relationships to disclose