Depression: The Fourth Pillar of Classifying Risk of Diabetes-Related Amputation in Veterans

Author(s): Brandon M. Brooks, Jaminelli Banks, Allison S. Arp, Vilayvanh Saysoukha, Bradley M. Brooks, Brady M. Brooks, Nichol L. Salvo, Alton R. Johnson, Donya A. Rabadi, Ashley M. Nettles, David G. Armstrong, Lee C. Rogers.

Background: Over half of the 100,000 lower extremity amputations in the United States every year are related to complications of diabetes mellitus, yet mental health and/or depression are not routinely addressed as an underlying contributor. To prevent amputations, the Veterans Health Administration (VHA) utilizes the PAVE program which classifies risk (FRS) as normal(0), low(1), moderate(2) or high risk(3) for amputation. We hypothesized that PAVE FRS 2 and 3 Veterans would have a higher prevalence of depression compared to PAVE FRS 0 Veterans.

Methods: We conducted a retrospective cohort study involving Veterans with type 2 diabetes mellitus. We developed logistic regression models with several explanatory variables (age, race, sex, BMI, A1c, PAVE FRS) and a diagnosis of depression as the outcome.

Results: 148 patients met our inclusion criteria. Among the explanatory variables, only PAVE FRS 2 (OR 5.07;p=0.001; 95%CI 1.87,13.72) and PAVE FRS 3 (OR 9.85;p=0.002;95% CI 2.25,43.18) were significant. Of note, the PAVE FRS 2 includes Veterans with a foot deformity and/or neuropathy but not a history of a DFU or amputation.

Conclusions: PAVE FRS 2 and 3 Veterans had greater odds of having a documented diagnosis of depression. There was no significant difference in the prevalence of depression between PAVE FRS 2 (no DFU or amputation) and PAVE FRS 3 Veterans (DFU, amputation). Given that depression is among the most treatable mental disorders and can occur prior to a DFU and/or amputation, we proposed a modified threatened limb classification system that accounts for depression in the Veteran population (WIfI’D)