Mental Health Linked to Amputation Risk in Diabetic Veterans

“Our findings suggest that foot care programs need to assess individuals for mental health functioning as a risk factor and to develop appropriate interventions to counteract this higher risk of major amputation,” write the study authors, led by Chin-Lin Tseng, Dr.P.H., of the VA New Jersey Health Care System, East Orange, N.J.

Dr. Tseng and colleagues analyzed a database of nearly 115,000 patients with diabetes who received care at Veterans Health Administration clinics from 1998 to 2000. All of the veterans were asked to complete a measure of mental health functioning.

Scores for mental health functioning were evaluated as a risk factor for diabetes-related amputations of the foot and leg. During 2000, “major” amputations (ankle or above) were required in 450 patients, while 431 underwent “minor” amputations (toes to ankle).

Veterans with lower scores for mental health functioning were at increased risk for amputations. This was so even when other important risk factors—including poor control of diabetes, smoking, less-frequent health care, and obesity—were taken into account. The overall rate of major amputations was 0.5 percent in veterans with below-average mental health scores, compared to 0.3 percent in those with above average scores and 0.2 percent for those at the highest level of mental health functioning.

On analysis including all risk factors, each five-point increase in mental health score was associated with a five percent decrease in the risk of major amputations. After adjustment, mental health functioning was no longer a significant risk factor for minor amputations.

Mental health scores were higher for veterans who had above a high school education, who were not obese, and who were not considered poor.

Amputations are a major complication of diabetes. Most studies of amputation risk factors have focused on medical conditions—for example, foot problems such as ulcers or infections or control of diabetes. Although some research has suggested that mental health care may affect the risk of diabetes-related amputations, the new study is the first to address this issue directly.

The results suggest that poor mental health functioning is an important risk factor for major amputations in diabetic veterans. Although the study cannot prove any cause-and-effect relationship, Dr. Tseng and colleagues believe that problems with mental health may interfere with needed diabetes care, including foot care.

The researchers urge medical professionals and patients to be aware of the possible link between mental health and amputation risk. They conclude, “Identifying patients who are at higher risk for major amputations due to poor mental health functioning may allow the dedication of resources and services to more closely supervise and manage their podiatric needs, perhaps leading to fewer amputations.”