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Kamalov Telman Tulyaganovich, Head of U Department of Center for the Scientific and Clinical Study of Endocrinology, Tashkent, Uzbekistan. E-mail: evovision@bk.ru
DEPRESSIVE AND ANXIETY DISORDERS IN PATIENTS WITH DIABETIC FOOT SYNDROME
Abstract: All patients had type 2 diabetes mellitus (DM) with mean duration of 12.8 ± 8.69 years (Me 11.5; IQR7.0-16.8) and mean DFS duration of 6.07 ± 4.78 years (Me 5.0; IQR2.0-10.0). Hamilton Depression Rating Scale (HDRS) was used to assess depressive symptomatology. Spielberger's STAI (State - Trait Anxiety Inventory) was used to assess a person's state anxiety. STAI indicated intermediate state anxiety (SA) in 20 (66.7%) of the examinees with DFS, high trait anxiety (TA) being found in 50%. Depressive disorders were diagnosed in 19 (63.3%) patients. Direct correlation between SA and TA in patients with DFS (r = 0.34; P < 0.05) was established; anxiety level being directly affected by duration of DM (r = 0.32; P < 0.05) and, to a greater degree, by the one of DFS (r = 0.41; P < 0.05). No correlation was found between glucose concentration and SA (r = 0.06; P > 0.05) or TA (r = 0.20; P > 0.05) or depressive symptomatology (r = 0.01; P > 0.05); HbA1c level correlating with TA (r = 0.43; P < 0.05), but not with SA (r = 0.11; P > 0.05) or depression (r = 0.24; P > 0.05). High TA was found in women more frequently (0R17.0; 95%CI 1.69-171.7; P = =0.02). Depression seemed independent either on DM duration (r = 0.06; P < 0.05), or on DFS duration (r = 0.17; P< < 0.05) or on DFS form (r = 0.19; P < 0.05).
Keywords: Diabetic foot syndrome, depressive and anxiety disorders.
Diabetes mellitus is a serious medical and social problem with DFS. Anxiety is known to precede depression in patients for public health systems worldwide. Bringing about early in- with type 2 diabetes mellitus, anxiety disorders without de-capacitation it is a disorder of high social significance. For the pression occurring in 60% of the patients [3, 5, 7, 12].
Simson et al. registered moderate and severe depressive symptoms before treatment in 16.2% and 18% of patients with DFS, respectively. High and intermediate anxiety was observed in 16.4% and 24.7% of the patients, respectively. A retrospective cohort study recruiting 531,973 diabetic patients in 2000-2004 demonstrated that in 33% of cases depression is associated with major amputations, but not with minor ones (Hazard Ratio (HR) 1.33; 95%CI 1.15-1.55 versus 1.01; 95%CI 0.90-1.13).
Materials and methods. 30 patients with DFS (18 men, 60.0% and 12, 40.0%) aged from 45 to 65 (mean age 63.8 ± 6.31 years, Me 11.5; IQR61.0-67.5) hospitalized at the Diabetic Foot Department, Center for the Scientific and Clinical Study of Endocrinology within the period from January to July 2013 were asked to complete a questionnaire. All patients had type 2 diabetes mellitus (DM) with mean duration of 12.8 ± 8.69 years (Me 11.5 years; IQR7.0-16.8) and mean DFS duration of 6.07 ± 4.78 years (Me 5.0; IQR2.0-10.0). Newly diagnosed DM and DFS were found in 1 (3.3%) and 8 (26.7%) patients, respectively. Neuropathic and neu-roischemic forms of DFS were registered in 24 (80.0%) and 6 (20.0%) patients, respectively. One third of the examinees (30.0%) had previously performed amputation of toes, feet
last decade its prevalence has been growing at a fearful rate. According to WHO experts, there were 98.9 million diabetics in 1989 worldwide, the value reaching 366 million people in 2011 and being predicted to rise to 552 million people by 2030 (IDF, 2011). Type 2 diabetes mellitus is the prevailing form, accounting for 85-97% of all cases [1].
More than 70% of patients with diabetes mellitus are at risk to develop diabetic foot syndrome (DFS), the complication associated with frequency of non-traumatic low extremity amputations ranging from 40 to 70%, [4, 21]. The patients are in constant fear of gangrene and amputation. The amputation of itselfis a potent negative psychological factor causing prolonged stress and accompanied by anxiodepressive disorders [1,17].
Compromised psychoemotional state of diabetics significantly affects clinical manifestations, progression and prognosis of the disease, considerably governing quality of life (QoL). In addition to QoL worsening, anxiety disorders hamper treatment of arterial hypertension in patients with DFS. Depressive disorders may thrice increase probability of lethal outcome in the patients [8, 9].
Thus, depressive and anxiety disorders in patients with diabetic foot syndrome press for their active identification and treatment. Numerous studies address depression in patients
and lower leg in medical history. The patients were comparable by age, body mass index (BMI) as well as by HbAlc and blood glucose level. All patients were under antihypergly-cemic therapy. All patients came to the hospital in a state of subcompensation carbohydrate metabolism (HbAlc 8.53 ± ± 1.77%, fasting and postprandial glucose 8.69 ± 2.44 and 9.88 ± 2.71 mmol/l, respectively).
To assess anthropometric parameters for all patients BMI or Quetelet index was calculated. The ortho-toluidine method was used to measure blood glucose by means of testing kits (Lachema, Czech Republic). The colorimetric method was used to measure HbAlc.
Patients with diabetic foot syndrome and non-psychotic psychiatric disorders in compliance with F40-F42 diagnose codes as per ICD-10, giving consent to participate were included into the study. Presence of other carbohydrate metabolism disorders besides type 2 DM, such as, DM due to genetic defects, pancreas and endocrine diseases, gestational diabetes as well as ischemic heart disease, chronic kidney disease, strokes and myocardial infarctions in medical history were the exclusion criteria.
Hamilton Depression Rating Scale (HDRS, 1967) was used to assess depressive symptomatology. A score of0-6 was considered normal with depressive symptoms absent. Scores of 7-16 and 17-27 indicated mild and moderate depression, respectively, severe depression being diagnosed with score higher than 27.
The Russian adaptation of Spielberger's STAI (State - Trait Anxiety Inventory) by Khanin Yu.L. (1978) was used to assess a person's state anxiety, that is, his/her anxiety level at the definite moment, and trait anxiety as his/her stable response. The level was considered low with score under 30; score ranging from 30 to 45 indicated intermediate anxiety and the one more than 45 characterized high level of anxiety [10].
All data was processed by means of a Microsoft Excel, STATISTICA 6 and BIOSTAT software packet. Logistic regression was used to calculate odds ratio (OR) and 95% confidence interval (CI). Statistical significance of differences between parameters was assessed by means of non-parametric X2 test (Pearson's criterion). Quantitative parameters are presented as M ± m as well as Median (Me) and 25th and 75th percentiles as Inter Quartile Range (IQR). Intergroup differences were considered significant at p < 0.05.
Results and discussion. STAI indicated intermediate state anxiety (SA) in 20 (66.7%) of our examinees with diabetic foot syndrome; high trait anxiety (TA) being found in 50%. Depressive disorders were diagnosed in 19 (63.3%) patients; mild and moderate depression registered in 11 (36.7%) and 8 (26.6%), respectively. No symptoms were observed in 11 patients (36.7%) (Fig.1).
State anxiety integrated assessment scored 39.3 ± ± 8.12 (Me 40.0; IQR34.0-44.0). Intermediate and high trait anxiety was registered in 46.7% (n = 14) and 50.0% (n = 15) patients, respectively; mean value scored 44.2 ± ± 10.4 (Me 45.0; IQR36.3-52.5). We have managed to establish direct correlation between SA and TA in patients with DFS (r = 0.34; P < 0.05); anxiety level being directly affected by duration of DM (r = 0.32; P < 0.05) and, to a greater degree, by the one of DFS (r = 0.41; P < 0.05). State anxiety declared itself in tension (10.0%) and unrest (43.3%); 23.3% of the examinees mentioned inner agitation, constraint and inability to relax as well as concerns over potential hypoglycemia and fainting, failure of attention.
Figure 1. Frequency of anxiety and depressive disorders in patients with DFS
Trait anxiety manifests as apprehension of various situations as threatening and dangerous ones directly correlating with HbA1c level. 56.6% of patients with DFS dreaded deterioration in their condition being in fear of the repeated amputations. Assessed by means of HDRS17 depression score ranged from 1 to 24, total value of 11.5 ± 6.96 (Me 11.5; IQR5.0-17.5) corresponding to mild depression.
Fisher et. al demonstrated that HbA1c level was associated with depression more significantly than with anxiety. There were twice more patients with the depression - anxiety combination than those with the disorders ad partem, anxiety
preceding depression in 50% of cases and the reverse order being found in 30% [7].
We failed to find any correlation between glucose concentration and SA (r = 0.06; P > 0.05) or TA (r = 0.20; P > 0.05) or depressive symptomatology (r = 0.01; P > 0.05). However, HbA1c level was found to correlate with TA (r = 0.43; P < 0.05), but not with SA (r = 0.11; P > 0.05) or depression (r = 0.24; P > 0.05). Anxiety disorders equifrequently occurred in women and men with DFS; low both SA (16.7%) and TA (5.6%) were typical of men, but high TA being found in women more frequently (0R17.0; 95% CI 1.69-171.7; P = 0.02) (Fig. 2).
Figure 2. Frequency of anxiety disorders in patients with DFS by sex
We failed to found any gender peculiarities in degree of depression. Thus, the mean value among men scored 11.6 ± 6.61 (Me 12.0; IQR5.75-17.0) versus 11.7 ± 2.04 (Me 9.0; IQR4.75-16.8; P = 0.98) among women. In addition, depression seemed independent either on DM duration (r = 0.06; P < 0.05), or on DFS duration (r = 0.17; P < 0.05) or on DFS form (r = 0.19; P < 0.05).
Anxiety disorders in patients with DM are known to be determined by response to the disease, associating not only with diagnose, onset and progression of debilitating complications, but also with necessity of self-care, potential limitations and changes in regular style and quality of life [11]. Of 1096 patients inquired in the frames of DIABASIS survey unrest, fear and spite were observed in 30%, 13% and 4%, respectively; 12% of the patients perceiving injustice in onset of the disease [14].
A component of psychoemotional stress, anxiety may provoke metabolic syndrome and insulin resistance, eventually resulting in type 2 DM [2, 16]. High trait anxiety is the evidence for self-doubt, effort to avoid critical situation and fear. Anxiodepressive disorders are conductive to higher risk of carbohydrate metabolism decompensation as well as to onset
and progression of complications. Activation of hypothalamo-pituitary-adrenal axis as well as extrinsic factors, facilitating reduction of patient compliance, are believed to underlie negative influence of affective disorders on blood glucose [7, 12]. Anxiodepressive disorders hamper reaching and maintaining prolonged DM compensation, worsening its prognosis. Underestimation of the effect depression exerts on DM course as well as untimely diagnosis and psycho-pharmacotherapy result in efficiency of diabetes care quality [6, 13, 15].
Conclusions
We registered intermediate state anxiety in most patients with DFS (66.7%), intermediate and high trait anxiety being found in 46.7% and 50.0%, respectively. Depressive disorders were diagnosed in 63.6%, mild form prevailing. Direct relationship was found between SA and TA levels (r=0.34; P < 0.05); positive correlation being observed between DM duration (r = 0.32; P < 0.05), the one of DFS (r = 0.41; P < 0.05) and anxiety level as well as between HbA1c and TA (r = 0.43; P < 0.05). Degree of depressive disorders was found independent of DM duration (r = 0.06; P < 0.05), DFS duration (r = 0.17; P < 0.05) and DFS form (r = 0.19; P < 0.05).
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