Patients with diabetes who have a confrontational coping style or who are depressed may be more likely to have impaired healing of their foot ulcers, based on findings from a prospective observational study.
“Psychological interventions that reduce depression and promote effective coping could significantly improve healing rates in this patient group,” wrote Dr. Kavita Vedhara of the University of Nottingham (England) and colleagues.
On average, 4%-10% of diabetic patients with diabetes mellitus have foot ulceration. “The emotional, physical, and financial costs are considerable, with foot ulcer patients reporting greater depression and poorer quality of life,” the authors wrote. Meanwhile, the complications cost the health care system millions of dollars, the researchers added (Diabetologia 2010;53:1590-8).
For 24 weeks, the investigators assessed 93 patients – 68 men with a mean age of 60 years – with neuropathic or neuroischemic diabetic foot ulcers. The patients were recruited from podiatry clinics between 2002 and 2008.
Clinical and demographic determinants of healing, psychological distress, coping styles, salivary cortisol, and levels of two types of matrix metalloproteinases were evaluated at baseline. The ulcers were assessed at 6, 12, and 24 weeks post baseline.
Of the patients with complete data for the primary analysis, 56 had a healed ulcer by week 24, and 37 remained unhealed. Of the unhealed patients, 14 had an amputation and 3 died during the follow-up period.
The primary analysis showed that the patients who had a tendency toward confrontational coping were less likely to have a healed ulcer by week 24. The results also showed that patients who exhibited clinical depression had smaller changes in ulcer size over time. In addition, patients with unhealed ulcers had lower levels of evening cortisol; higher levels of pro-MMP2, a type of matrix metalloproteinase; and a greater cortisol awakening response at baseline.
“The present study suggests that depression and coping style are associated with a greater likelihood of diabetic foot ulcers not healing over a 6-month period, albeit through seemingly independent pathways, and that cortisol and pro-MMP2 may be among the mechanisms underlying these relationships,” the researchers wrote.
The study was limited by the sample size and by the fact that the assessment of wound size was restricted to the surface of the wounds and did not include measures below the skin.
Because the study is one of the few to investigate the relationship between stress and healing of diabetic foot ulcers, the authors concluded that more research is needed to “elucidate these mechanisms and to develop interventions, in particular those geared to modifying coping style and distress ... in order to improve clinical outcomes in this patient group.”
The investigators reported having no conflicts of interest.