The Depression Paradox: Does Depression Increase Risk for Foot Ulceration (or not?)

These intriguing snippets from Lashmi Shankhdhar, MD:

Find 3 different views regarding relationship between Depression and diabetic foot ulcer healing:

The depression paradox:
Psychosocial factors such as cognitive function and depression have long been suspected of contributing to ulcer recurrence.
1.    In 2008, for example, Italian researchers reported in the Journal of the American Podiatric Medical Association that in 80 type 2 diabetes patients studied, the 60% who suffered recurrent ulcers had higher levels of depressive symptoms than others, among other factors.
(Monami M, Longo R, Desideri CM, et al. The diabetic person beyond a foot ulcer: healing, recurrence, and depressive symptoms. J Am Podiatr Med Assoc 2008;98(2):130-136.)

2.    A 2009 study from Germany, reported in Diabetes Care, concluded that cognitive function was not an important determinant of foot reulceration

(Kloos C, Hagen F, Lindloh C, et al. Cognitive function is not associated with recurrent foot ulcers in patients with diabetes and neuropathy. Diabetes Care 2009;32(5):894-896.)
3.    A U.S. study of 333 patients with neuropathy reported, oddly enough, that depression was associated with an increased risk of first foot ulcers but not of recurrent ones.
It’s an interesting paradox, because you’d think that if the first ulcer were associated with depressive symptoms, the second would be even more so,” said Cavanagh, one of the coauthors. “Whether there is a cause-and-effect relationship between psychosocial factors and outcome, or whether the psychological factors follow the outcome, is not something our study design could untangle.”
 (Gonzalez JS, Vileikyte L, Ulbrecht JS, et al. Depression predicts first but not recurrent diabetic foot ulcers. Diabetologia 2010 June 

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