How Neuropathy, Pain, and Depression Can Lead to Amputation
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Q: How does depression contribute to the risk of amputation in patients with diabetes?
Sugar impacts mood. Period. That is a fact. Looking at the specifics, major depressive disorder, more commonly called depression, is associated with non-adherence, poor self-care, no-shows, and poor dietary choices. We know that people with diabetes are 2 to 3 times more likely to have depression than people without diabetes.1 Further, only 25% to 50% of people with diabetes who have depression get diagnosed and treated.1
What makes this even more tragic is that treatment for depression—be it psychotherapy, medication, or both—is usually very effective.
Q: How can DPMs help patients who may have depression?
The Merit-based Incentive Payment System (MIPS), the program that determines Medicare payment adjustments, lists screening for depression as a quality measure (#134 to be exact). From my experience, podiatric physicians and surgeons can and should screen the diabetic population for depression. Per the Quality Measure, screening for depression and making the appropriate referral are all that need to be done to meet the quality measure. Podiatry and psychiatry are natural allies; the same goes for all other mental health clinicians such as clinical psychologists and psychotherapists/counselors.
I believe that DPMs who make the appropriate referral to mental health clinicians will not only be helping that patient, but they will probably have the opportunity to help additional patients via referrals from mental health clinicians. Ultimately, podiatric physicians and surgeons stand at the intersection of two public health crises: The diabetes pandemic and the mental health crisis in America. What you choose to do about these issues matters!
Q: What are some depression screening tools DPMs can use?
The PHQ-9 is what I use to screen for depression. It is easy to administer (only 9 questions) and takes no more than a few minutes to complete. The scores are easy to interpret. I make a referral with a score of 10 or more; a PHQ-9 score ≥ 10 has a sensitivity of 88% and a specificity of 88% for major depressive disorder. For patients with scores of 5–9, it all depends on the patient's situation, duration of their symptoms, and functional impairment; it's a maybe for me as far as referral for depression. A patient with a score of less than 5 is less likely to have depression.
Brandon M. Brooks, DPM, MPH, practices at the Columbia VA Health Care System in Columbia, SC. He became the American Podiatric Medical Association’s 6th Public Health Fellow at the Geisel School of Medicine at Dartmouth College in Hanover, NH where he finished at the top of his class for his MPH degree. He is board qualified in podiatric surgery by the American Board Podiatric Medicine. Dr. Brooks is best known for his opioid research, which resulted in the Journal of the American Podiatric Medicine Association’s opioid issues in 2023, which featured eleven of his manuscripts.
Reference
1. Brooks BM, Shih CD, Brooks BM, Tower DE, Tran TT, Simon JE, Armstrong DG. The diabetic foot-pain-depression cycle. J Am Podiatr Med Assoc. 2023 May-Jun;113(3):22-126. doi: 10.7547/22-126. PMID: 37463195.
