title: Depression and incident lower limb amputations in veterans with diabetes.
abstract: OBJECTIVE
  Depression is associated with a higher risk of macrovascular and microvascular complications and mortality in diabetes, but whether depression is linked to an increased risk of incident amputations is unknown. We examined the association between diagnosed depression and incident non-traumatic lower limb amputations in veterans with diabetes.
  
  
  METHODS
  This was a retrospective cohort study from 2000-2004 that included 531,973 veterans from the Diabetes Epidemiology Cohorts, a national Veterans Affairs (VA) registry with VA and Medicare data. Depression was defined by diagnostic codes or antidepressant prescriptions. Amputations were defined by diagnostic and procedural codes. We determined the HR and 95% CI for incident non-traumatic lower limb amputation by major (transtibial and above) and minor (ankle and below) subtypes, comparing veterans with and without diagnosed depression and adjusting for demographics, health care utilization, diabetes severity and comorbid medical and mental health conditions.
  
  
  RESULTS
  Over a mean 4.1 years of follow-up, there were 1289 major and 2541 minor amputations. Diagnosed depression was associated with an adjusted HR of 1.33 (95% CI: 1.15-1.55) for major amputations. There was no statistically significant association between depression and minor amputations (adjusted HR 1.01, 95% CI: 0.90-1.13).
  
  
  CONCLUSIONS
  Diagnosed depression is associated with a 33% higher risk of incident major lower limb amputation in veterans with diabetes. Further study is needed to understand this relationship and to determine whether depression screening and treatment in patients with diabetes could decrease amputation rates.
authors.affiliation: VA Health Services Research & Development Center of Excellence, Seattle, WA, USA. lisahw@u.washington.edu
authors.forename: Lisa H
authors.initials: LH
authors.lastname: Williams
authors.forename: Donald R
authors.initials: DR
authors.lastname: Miller
authors.forename: Graeme
authors.initials: G
authors.lastname: Fincke
authors.forename: Jean-Philippe
authors.initials: JP
authors.lastname: Lafrance
authors.forename: Ruth
authors.initials: R
authors.lastname: Etzioni
authors.forename: Charles
authors.initials: C
authors.lastname: Maynard
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Raugi
authors.forename: Gayle E
authors.initials: GE
authors.lastname: Reiber
mesh_terms: D000368:Aged; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D015331:Cohort Studies; D015897:Comorbidity; D003866:Depressive Disorder / Q000453:epidemiology*; D017719:Diabetic Foot / Q000453:epidemiology / Q000523:psychology / Q000601:surgery; D005260:Female; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D014728:Veterans / Q000706:statistics & numerical data*
references.citation: Gen Hosp Psychiatry. 2007 Nov-Dec;29(6):537-46
references.pmid: 18022047
references.citation: Contemp Clin Trials. 2010 Jul;31(4):312-22
references.pmid: 20350619
references.citation: Diabetes Care. 2007 Jun;30(6):1473-9
references.pmid: 17363754
references.citation: J Gen Intern Med. 2008 Oct;23(10):1571-5
references.pmid: 18649108
references.citation: Psychosom Med. 2007 Jul-Aug;69(6):537-42
references.pmid: 17634567
references.citation: Diabetes Care. 2008 Jun;31(6):1155-9
references.pmid: 18332158
references.citation: J Diabetes Complications. 2007 Nov-Dec;21(6):341-9
references.pmid: 17967704
references.citation: Psychosom Med. 2001 Jul-Aug;63(4):619-30
references.pmid: 11485116
references.citation: Diabetes Care. 1999 Jul;22(7):1029-35
references.pmid: 10388962
references.citation: Brain Behav Immun. 2002 Feb;16(1):74-84
references.pmid: 11846442
references.citation: Psychosom Med. 2007 Sep-Oct;69(7):597-605
references.pmid: 17766687
references.citation: J Rehabil Res Dev. 2006 Mar-Apr;43(2):227-38
references.pmid: 16847789
references.citation: Gen Hosp Psychiatry. 2006 Jan-Feb;28(1):9-17
references.pmid: 16377360
references.citation: Circulation. 2002 Nov 19;106(21):2659-65
references.pmid: 12438290
references.citation: Ann Intern Med. 1992 Jul 15;117(2):97-105
references.pmid: 1605439
references.citation: Diabetes Care. 2010 Apr;33(4):706-13
references.pmid: 20097780
references.citation: Diabetes Care. 2004 May;27 Suppl 2:B39-44
references.pmid: 15113781
references.citation: Diabetes Care. 2004 May;27 Suppl 2:B10-21
references.pmid: 15113777
references.citation: Am J Psychiatry. 2004 Apr;161(4):654-61
references.pmid: 15056511
references.citation: Diabetes Care. 2007 Jul;30(7):1807-12
references.pmid: 17475942
references.citation: Circulation. 2008 Feb 12;117(6):743-53
references.pmid: 18212285
references.citation: Psychosom Med. 2001 Mar-Apr;63(2):216-20
references.pmid: 11292268
references.citation: Diabetes Care. 2003 Oct;26(10):2822-8
references.pmid: 14514586
references.citation: Diabetes Care. 2001 May;24(5):860-4
references.pmid: 11347744
references.citation: Diabetes Res Clin Pract. 1996 Apr;32(1-2):19-25
references.pmid: 8803478
references.citation: N Engl J Med. 2005 Jan 27;352(4):341-50
references.pmid: 15673800
references.citation: Ostomy Wound Manage. 2007 Oct;53(10):60-6
references.pmid: 17978416
references.citation: Adm Policy Ment Health. 2006 May;33(3):331-41
references.pmid: 16755394
references.citation: Diabetes Care. 2007 Apr;30(4):872-7
references.pmid: 17392548
references.citation: Diabetes Care. 2005 Oct;28(10):2378-83
references.pmid: 16186266
references.citation: Diabetes Care. 2001 Jun;24(6):1069-78
references.pmid: 11375373
references.citation: Res Nurs Health. 2005 Dec;28(6):488-95
references.pmid: 16287052
references.citation: Diabetes Care. 2004 Sep;27(9):2154-60
references.pmid: 15333477
references.citation: Foot Ankle Int. 2005 Feb;26(2):128-34
references.pmid: 15737254
references.citation: Diabetes Care. 2003 Sep;26(9):2595-7
references.pmid: 12941724
references.citation: Biol Psychiatry. 2003 Aug 1;54(3):248-61
references.pmid: 12893101
references.citation: J Am Podiatr Med Assoc. 2008 Mar-Apr;98(2):130-6
references.pmid: 18347122
references.citation: Vasc Med. 2005 Aug;10(3):199-206
references.pmid: 16235773
references.citation: Am J Manag Care. 2004 Nov;10(11 Pt 2):886-92
references.pmid: 15609743
references.citation: Shock. 2007 Mar;27(3):305-11
references.pmid: 17304112
references.citation: Brain Behav Immun. 2008 Nov;22(8):1173-7
references.pmid: 18571893
references.citation: J Vasc Surg. 2007 Apr;45(4):744-50
references.pmid: 17303367
references.citation: Diabetes Care. 1990 May;13(5):513-21
references.pmid: 2351029
references.citation: Diabetes Care. 2005 Nov;28(11):2668-72
references.pmid: 16249537
references.citation: Diabet Med. 2006 Nov;23(11):1165-73
references.pmid: 17054590
references.citation: JAMA. 2008 Jun 18;299(23):2751-9
references.pmid: 18560002
references.citation: Diabetes Care. 1995 Apr;18(4):509-16
references.pmid: 7497861