title: Coping style and depression influence the healing of diabetic foot ulcers: observational and mechanistic evidence.
abstract: OBJECTIVE
  Experimental evidence suggests that the healing of diabetic foot ulcers is affected by psychosocial factors such as distress. We examined this proposal in a prospective study, in which we considered the role of psychological distress and coping style in the healing of diabetic foot ulcers over a 24 week period. We also explored the role of salivary cortisol and matrix metalloproteinases (MMPs) as potential mechanisms.
  
  
  METHODS
  For this prospective observational study we recruited 93 (68 men; mean age 60 years) patients with neuropathic or neuroischaemic diabetic foot ulcers from specialist podiatry clinics in secondary care. Clinical and demographic determinants of healing, psychological distress, coping, salivary cortisol and both MMP2 and MMP9 were assessed at baseline. Ulcers were assessed at baseline and at 6, 12 and 24 weeks post-baseline. The primary outcome was ulcer status at 24 weeks, i.e. healed vs not healed.
  
  
  RESULTS
  After controlling for clinical and demographic determinants of healing, ulcer healing at 24 weeks was predicted by confrontation coping, but not by depression or anxiety. Patients with unhealed ulcers exhibited greater confrontation coping (model including depression: OR 0.809, 95% CI 0.704-0.929, p = 0.003; model including anxiety: OR 0.810, 95% CI 0.704-0.930, p = 0.003). However, change in ulcer size over the observation period was associated with depression only (p = 0.04, d = 0.31). Healed ulcers by 24 weeks were also associated with lower evening cortisol, higher precursor MMP2 and a greater cortisol awakening response.
  
  
  CONCLUSIONS
  Confrontation coping and depression predict ulcer healing. Our preliminary enquiry into biological mechanisms suggests that cortisol and precursor MMP2 may underlie these relationships.
authors.affiliation: Institute of Work, Health and Organisations, International House, University of Nottingham, Jubilee Campus, Nottingham NG8 1BB, UK. Kavita.Vedhara@nottingham.ac.uk
authors.forename: K
authors.initials: K
authors.lastname: Vedhara
authors.forename: J N V
authors.initials: JN
authors.lastname: Miles
authors.forename: M A
authors.initials: MA
authors.lastname: Wetherell
authors.forename: K
authors.initials: K
authors.lastname: Dawe
authors.forename: A
authors.initials: A
authors.lastname: Searle
authors.forename: D
authors.initials: D
authors.lastname: Tallon
authors.forename: N
authors.initials: N
authors.lastname: Cullum
authors.forename: A
authors.initials: A
authors.lastname: Day
authors.forename: C
authors.initials: C
authors.lastname: Dayan
authors.forename: N
authors.initials: N
authors.lastname: Drake
authors.forename: P
authors.initials: P
authors.lastname: Price
authors.forename: J
authors.initials: J
authors.lastname: Tarlton
authors.forename: J
authors.initials: J
authors.lastname: Weinman
authors.forename: R
authors.initials: R
authors.lastname: Campbell
mesh_terms: D000223:Adaptation, Psychological; D000368:Aged; D000704:Analysis of Variance; D002851:Chromatography, High Pressure Liquid; D003866:Depressive Disorder / Q000523:psychology*; D017719:Diabetic Foot / Q000503:physiopathology / Q000523:psychology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013315:Stress, Psychological / Q000523:psychology*; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology
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