In our January issue, we featured the lonely experience of amputees with diabetes. Our article pointed out that people with diabetes are up to three times as likely to experience depression as people without diabetes. They’re also susceptible to “diabetes distress,” which erodes people’s energy and motivation to maintain disciplined habits of self-care.
More evidence of these phenomena surfaced last month month in the journal Seminars in Vascular Surgery, where a new study argues that depression stemming from diabetes-related amputation is very real and potentially very dangerous. The paper coins a new acroynm for mental health problems arising from dysvascular limb-loss : DREADD, or “Diabetes-Related Extremity Amputation Depression and Distress.” DREADD, in turn, is bound up in the diabetic foot-pain-depression cycle, which was first described in a 2023 paper as a tangle of observable symptoms (weight gain, poor sleep, inactivity, self-medication) and invisible phenomena (stress, shame, social withdrawal, poor gut health).
“Depression is relevant throughout the progression to amputation in patients with T2DM,” the authors of the DREADD paper observe. “[It] has been identified as both a predictor of nontraumatic major lower limb amputation in diabetic populations and of postamputation depression.” In other words, depression very often precedes, and may increase the likelihood of, diabetes and limb loss. This complicates the task of measuring whether depressive symptoms worsen after limb loss (and, if so, by how much).
Diabetes-related Limb-Loss Depression: The Evidence
Depressive symptoms can be difficult to assess using quantitative methods alone, so the authors gathered both quantitative and qualitative evidence. They also chose to limit their research to people who experienced the least traumatic diabetes-related amputations—a toe or a finger. Such “minor” amputations are the most common type of diabetes-related limb loss, and they often predict subsequent loss of a major limb.
We’ll get to the quantitative outcomes shortly, but we found the qualitative data to be more powerful and more illustrative than the numerical findings. Qualitative evidence was gathered via post-amputation interviews with approximately 20 individuals. The paper catalogues these responses into three major themes: Depression (feelings of failure and hopelessness), Distress (worry, anger, and frustration), and Barriers to Mental Heatlh Care (shame and stigma). The published excerpts from these interviews would have fit very nicely in our January article on diabetes and limb loss:
- “I felt like failure. I didn’t want to get up and go work. I didn’t take my meds. My wife was concerned I knew I let everyone down.”
- “At first, I thought it was more going be more than a toe, I asked myself if I would want to end it. Would I want to continue to live? I wanted to keep positive, but I had these thoughts. I didn’t even know if I could live or walk without my toe.”
- “It’s scary to lose part of your body, you know, because it’s like what is next? My uncle lost a toe and next thing was the foot. I couldn’t sleep for days after my toe.”
- “I was angry. I didn’t want to see my doc. I thought he did this to me. I should have had another opinion, option, or something. I listened to him, and I wished I never did this [amputation]. I can’t take it back.”
- “I am still embarrassed to talk about it. My late father would be ashamed.”
- “I was ashamed. I caused this, so maybe I should be sad all the time. Maybe it’s what I deserve.”
“The qualitative aspect of this study demonstrates that non- traumatic amputations can be a traumatic experience for patients,” the authors write. “Some patients with diabetic foot disease are noted to have a greater fear of major lower extremity amputation than death.”
The quantitative portion of the study was based on the Patient Health Questionnaire-9 (PHQ-9), which healthcare providers in many disciplines commonly use to screen for clinical depression. The typical PHQ-9 cutoff score is ten; anything higher than that indicates depression that’s serious enough to warrant some form of treatment. For this part of the study, the researchers administered the PHQ only to participants who’d been screened prior to their amputations, making it possible to compare the numbers before and after limb loss. The average PHQ score before limb loss was 3.65, far below the cutoff figure. After limb loss, however, the average score leaped to 12.65, well within the range of moderate to serious depression. “One of the primary concerns in depressed and diabetic populations is that depression is associated with treatment nonadherence and lack of self-care, which may directly contribute to poorer outcomes,” the authors add.
In their conclusion, the researchers recommend that people with type 2 diabetes be screened for depression before they’re at risk of even losing a toe or finger. They also argue that multidisciplinary limb-preservation teams should include psychiatrists and/or other mental health specialists. Finally, they note the potential for the emergence a psychiatric subspecialty focused on diabetes and its complications, including limb loss.
The full paper, “Diabetes-Related Extremity Amputation Depression and Distress (DREADD): A Multimethod Study,” is available through Science Direct.
