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Saturday, March 5, 2011

Are Diabetic Foot Ulcers Affected By Stress?

By Elaine R. Ferguson, MD

Recent research conducted by health psychology researchers at the University of Nottingham in Britain, has found that diabetics with diabetes-related foot ulcers experience different rates of healing, depending on the way they cope and their psychological state of mind.

The large study published in the journal Diabetologia in August, 2010 determined that healing or deterioration of the diabetes related foot ulcers is associated with the manner diabetic patients cope with the disease and their levels of depression. The research conducted by Professor Kavita Vedhara from the University's Institute of Work, Health and Organizations, triggered a follow-on project to develop psychological treatments designed to reduce depression and help patients in coping more effectively with this debilitating and potentially life-threatening condition.

Foot ulcers are open lesions (sores) that form usually as a result of a minor skin injury that fails to heal because of circulation and metabolic dysfunction caused by diabetes. Almost fifteen per cent of people with diabetes, both Type 1 and Type 2, at some point develop foot or leg ulcers with many experiencing depression and poorer quality of life as a result.

The increased death rate and complications caused by the condition are estimated to cost almost half a billion dollars in England each year. The costs are increased by slow healing rates with two thirds of ulcers remaining unhealed after 20 weeks of treatment. The five year amputation and death rates among patients are 19 per cent and 44 per cent respectively. Ulcers are the cause of approximately four out of five lower leg amputations and half of diabetes-related hospital admissions.

Over the course of the five-year study 93 patients (68 men and 25 women) with diabetic foot ulcers were recruited from specialist podiatry clinics across the country. Clinical and demographic determinants of healing; psychological distress, coping style and levels of the stress hormone, cortisol in saliva were assessed and recorded at the start of a 24 week monitoring period. The size of each patient's ulcer was also measured at the start, and then at 6, 12 and 24 weeks to record the extent of healing or otherwise of the ulcer. The study determined that the possibility of the ulcer healing over a 6 month period was linked to and predicted by how person coped. Interestingly, patients with a 'confrontational' manner of coping (a style characterised by a desire to take control) with the ulcer and its treatment were less likely to have a healed ulcer at the end of the 24 week period.

Professor Vedhara stated, "My colleagues and I believe that this confrontational approach may, inadvertently, be unhelpful in this context because these ulcers take a long time to heal. As a result, individuals with confrontational coping may experience distress and frustration because their attempts to take control do not result in rapid improvements."

An evaluation of each patient examined the relationship of psycho-social factors with the change in the size of the ulcer over the observation period. While the initial analysis determined that only confrontation coping, not anxiety or depression, was a significant predictor of healing, the second showed that depression was a significant predictor in how the size of the ulcer changed over time, with patients with clinical depression showing smaller changes in ulcer size over time i.e., they showed less improvement or healing.

The research project was funded by the Medical Research Council. A second project is under way, funded by a grant from the National Institute for Health Research. This will develop and pilot a psychological intervention to reduce the risk of ulcers recurring in patients with a history of diabetic ulcers.

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