SLR - September 2014 - Timothy Karthas

High Levels of Anxiety and Depression in Diabetic Patients with Charcot Foot

Reference: Chapman Z, Shuttleworth CMJ, Huber JW. High Levels of Anxiety and Depression in Diabetic Patients with Charcot Foot. Journal of Foot and Ankle Research 2014, 7: 22.

Scientific Literature Review

Reviewed By: Timothy Karthas, DPM
Residency Program: Mount Auburn Hospital

Podiatric Relevance: Charcot arthropathy is one of the most difficult pathologies encountered by the podiatric physician, as it can result in a variety of complex deformities that can challenge even the best in the field. Most practitioners are aware of the multiple physical co-morbidities, such as obesity, that are present in patients with Charcot. However, less is known about the psychological illnesses present in patients with Charcot foot, as there has been no previous literature on the topic. The authors of this study aimed to assess both the mental health status of patients with diabetes and Charcot foot, as well as the socio-demographic factors that moderate mental health in these patients.

Methods: Fifty patients (males 62 percent; mean age 62.2 ±8.5 years) had their risk of anxiety and depression analyzed by means of the Hospital Anxiety and Depression Scale (HADS), a questionnaire that is widely accepted in psychiatric literature for its ability to reduce confounders. Inclusion criteria included the necessity of a diagnosis and diagnosis date by an expert clinician, and that the Charcot was located in the anatomical foot. Exclusion criteria included any active ulceration, amputation, pregnancy, learning disability, inability to read or write English, other significant acute or chronic illnesses, or patients on psychoactive drugs or receiving psychiatric therapy. In addition, the participants recorded their demographic information on a separate collection sheet to be analyzed. This information included age, sex, ethnicity, marital status, employment status, and location of deformity. Statistical comparison of the data was then carried out using a study by Collins et al., who studied HADS scores in general diabetic patients, as a reference point.

Results: According to HADS, a normal score is considered to be <8, borderline risk is 8-10, and >10 is intermediate risk. The mean anxiety score in the patients studied was 6.4 ±4.4, and the mean depression score was 6.3 ±3.6.  Increased risk of anxiety and depression (>7 HADS score) was found in 42 percent of the patients. Females were found to have significantly higher risks of depression and anxiety. Black Minority Ethnicity (BME) and unemployment was found to result in significantly higher risks of depression, but not anxiety. No significant difference was observed for age, marital status, or duration of diabetes or Charcot. Analysis of the study by Collins et al. found that 29 percent and 22 percent of 1308 type two diabetics studied had increased risk for anxiety and depression respectively. This study found that compared to patients with diabetes alone, patients with Charcot foot and diabetes have odds of 1.8 for anxiety and 2.5 for depression.

Conclusions: The risk of anxiety and depression is high in patients with Charcot foot, and is double that of diabetes alone. Socio-demographics also play a role in anxiety and depression risks in these patients, as being female, BME, and non-working all increase risk. Studies on outcomes of patients with diabetes and depression have shown worse outcomes with treatment measures and worse morbidity. With the risk of anxiety and depression being even greater than that of diabetes alone in this study, the podiatric physician needs to be aware of which patients may need a psychological screening. The goal is that by getting psychological treatment for those that need it, better treatment outcomes may be possible.  

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