With commentary by Joel Zonszein, MD, director of the Clinical Diabetes Center, Montefiore Medical Center, the Bronx, New York; and Diane Maydick, EdD, RN, assistant professor of nursing, Long Island University, Brooklyn.
A diagnosis of diabetes brings with it an increased risk of depression, as experts have long known. About 20 to 40% of the 29 million Americans with diabetes also are clinically depressed.
"Diabetic foot ulcers add even more costs and stress, on top of the depression and diabetes,'' says Diane Maydick, EdD, RN, assistant professor of nursing at Long Island University's (LIU) Harriet Rothkopf Heilbrunn School of Nursing, Brooklyn. Dr. Maydick, along with Anna M. Acee, EdD, associate professor of nursing at LIU, wrote a review summarizing what is known about diabetic foot ulcers that occur along with depression. It is published in the February issue of Home Healthcare Now.
About 2 or 3% of those with diabetes will develop a diabetic foot ulcer each year, Dr. Maydick says. Over a lifetime, the likelihood of a person with diabetes getting a diabetic foot ulcer is as high as 25%, she found. The costs of care can be staggering, she says. The estimates range from about $3,000 for a less severe ulcer to more than $100,000 for one that progresses in severity so much that it requires foot amputation.
Most of the 73,000 amputations performed on adults with diabetes in 2010 were due to a diabetic foot ulcer, the researchers say.
In one study that found a link between depression and foot ulcers, researchers looked at more nearly 3,500 patients with diabetes and found those who had a major depressive disorder had two times the risk of getting a diabetic foot ulcer over a four-year period than those who did not have serious mental health issues.
Other researchers have found that a third of the 253 people studied who had their first diabetic foot ulcer also suffered from depression.
It's not always possible to determine which came first, the diabetes or the depression and other complications, says Joel Zonszein, MD, director of the Clinical Diabetes Center at Montefiore Medical Center, the Bronx, and professor of clinical medicine at Albert Einstein College of Medicine. He reviewed the report.
"If you look at a patient with diabetes who is treated [medically] well and has no complications, the amount of depression is less [typically],'' he says. Often, those who have well-controlled diabetes do not experience depression, he says. Those whose diabetes is not well-managed, he finds, often do have depression.
In those who have both depression and diabetes, research suggests that they are more likely to get other complications, Dr. Zonszein says, and that may include foot ulcers. The report, he says, is a good wake-up call to both patients and their doctors to consider the whole person.
"Very often we start focusing on the treatment of the foot ulcer,'' Dr. Zonszein says. While that is important, doctors and patients should also consider the state of the diabetes management and whether depression might also be at play, he says.
The bad news, he says, is that treating the depression does not always seem to improve the outcome for the diabetes, he says. Even so, the goal should be to treat all the conditions as best as possible, he says.
If you have diabetes, you may develop neuropathy, a loss of sensation. So you may not notice shoes rubbing your feet, for instance, until you have an area that becomes sore and perhaps ulcerated.
It's crucial, she says, to ''make sure you take good care of your feet. That involves a lengthy list, including inspecting the feet daily for any signs of wounds, cuts or ulcers. Nails must be cut straight across, not curved, to reduce the risk of ingrown toenails, which can lead to problems.
If you get a pedicure, don't allow your pedicurist to cut off calluses with a razor, Dr. Maydick says. "If you get a cut it could get infected," she says.
Besides wearing properly fitting shoes, Dr. Maydick tells those with diabetes to wear clean, white cotton socks and avoid putting lotion between toes or using heating pads on the feet.