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International Journal of Rehabilitation Research:
doi: 10.1097/MRR.0b013e328356429d
Original articles

How depressive levels are related to the adults’ experiences of lower-limb amputation: a mixed methods pilot study

Senra, Hugo

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Author Information

Centre of Psychology Research Unit, Faculty of Psychology and Educational Sciences, University of Porto, Porto, Portugal

Correspondence to Hugo Senra, PhD, Centre of Psychology Research Unit, Faculty of Psychology and Educational Sciences, University of Porto, Rua Alfredo Allen, 4200-135 Porto, Portugal Tel: +351 220 400 617; e-mail: hugo_senra@hotmail.com

Received April 3, 2012

Accepted May 14, 2012

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Abstract

The current pilot study aims to explore whether different adults’ experiences of lower-limb amputation could be associated with different levels of depression. To achieve these study objectives, a convergent parallel mixed methods design was used in a convenience sample of 42 adult amputees (mean age of 61 years; SD=13.5). All of them had undergone lower-limb amputation after the age of 18 years and were being followed up at the Physical Medicine and Rehabilitation Department of a General Hospital. A semistructured interview was conducted to explore patients’ experiences of amputation, and the Centre for Epidemiologic Studies Depression Scale was applied to assess depressive levels. In total, 31% of the patients fulfilled the Centre for Epidemiologic Studies Depression Scale criteria for depression. Higher depressive levels (P<0.05) were found in patients who manifested greater self-awareness of impairment, lower identification with the impairment, and a poorer perception of well-being and social support. The results suggest that the increase in depressive levels in amputees may be associated with adaptive dimensions of the emotional experience of impairment, rather than itself being a mere sign of maladjustment or negative coping.

Die vorliegende Pilotstudie untersucht, ob die verschiedenen Erfahrungen von Erwachsenen nach Amputation der unteren Extremität(en) mit unterschiedlichen Depressionsformen in Verbindung gebracht werden können. Zur Erreichung unserer Studienziele wurde ein konvergentes, paralleles Mixed Methods Design bei einer nichtrepräsentativen Stichprobe (Convenience Sample) von 42 erwachsenen Amputierten (mittleres Alter: 61 Jahre; Sta=13.5) angewandt. Die Studienteilnehmer hatten sich alle im Erwachsenenalter einer Amputation der unteren Extremität(en) unterziehen müssen und wurden in der Physiatrie und der Rehabilitation eines allgemeinen Krankenhauses nachversorgt. Ein semistrukturiertes Interview wurde zur Evaluierung der Erfahrungen der Patienten mit der Amputation durchgeführt, und mit Hilfe der Selbstbeurteilungsskala Center of Epidemiologic Studies Depression wurde der Schweregrad der Depressionen evaluiert. Insgesamt 31% der Patienten erfüllten die Kriterien für eine Depression laut der Selbstbeurteilungsskala Center of Epidemiologic Studies Depression. Höhere depressive Schweregrade (P<0.05) zeigten sich bei Patienten mit einem höheren Minderwertigkeitsgefühl wegen ihrer Behinderung, einer geringeren Identifizierung mit der Behinderung sowie einer schlechteren Wahrnehmung von Wohlbefinden und sozialer Unterstützung. Unsere Ergebnisse legen den Schluss nahe, dass der Anstieg des depressiven Schweregrads bei Amputierten möglicherweise mit den adaptiven Dimensionen der emotionalen Erfahrung der Behinderung zusammenhängt und nicht nur ein bloßes Zeichen der mangelnden Anpassungsfähigkeit oder negativen Bewältigung ist.

Este estudio piloto tiene como objetivo investigar si las diferentes experiencias de los adultos que han sufrido la amputación de un miembro inferior pueden asociarse con distintos grados de depresión. Con el fin de lograr los objetivos de este estudio, se utilizó un diseño de método mixto paralelo convergente en una muestra de conveniencia de 42 adultos amputados (edad media de 61 años; DE=13.5). Todos los adultos habían sufrido la amputación de un miembro inferior a una edad superior a los 18 años y estaban siendo sometidos a un seguimiento por parte del departamento de rehabilitación y medicina física de un hospital general. Se llevó a cabo una entrevista semiestructurada para evaluar las experiencias de los pacientes con respecto a la amputación y se aplicó la Escala de Depresión del Centro de Estudios Epidemiológicos para examinar el grado de depresión. En total, el 31% de los pacientes cumplieron con los criterios de depresión de la Escala de Depresión del Centro de Estudios Epidemiológicos. Se observó un grado superior de depresión (P<0.05) en aquellos pacientes que manifestaron una mayor conciencia de su discapacidad, una menor identificación con la discapacidad y una percepción más deficiente del apoyo social y del bienestar. Los resultados de este estudio sugieren que el aumento del grado de depresión en las personas amputadas puede estar asociado con las dimensiones adaptativas de la experiencia emocional con respecto a la discapacidad, en lugar de tratarse simplemente de un mero síntoma de inadaptación o afrontamiento negativo.

L'étude pilote en cours vise à explorer dans quelle mesure les expériences que différents adultes ont de l'amputation d'un membre inférieur pourraient être associées à différents niveaux de dépression. Pour atteindre nos objectifs d'étude, une conception à méthode mixte parallèle-convergente été adoptée dans un échantillon de convenance de 42 amputés adultes (âge moyen 61 ans, ÉT=13.5). Tous les sujets avaient subi une amputation d'un membre inférieur après l'âge de 18 ans et étaient suivis au service de médecine physique et de rééducation d'un hôpital général. Un entretien semi-structuré a été réalisé pour explorer les expériences de l'amputation qu'avaient les patients, et l'échelle de dépression du centre d'études épidémiologiques a été appliquée pour évaluer les niveaux de dépression. Au total, 31% des patients remplissaient les critères de l'échelle de dépression du centre d'études épidémiologiques. Des niveaux dépressifs élevés (P<0.05) ont été identifiés chez les patients qui manifestent une plus grande conscience de soi de la déficience, une moindre identification avec la déficience, et une moins bonne perception de bien-être et de soutien social. Nos résultats suggèrent que l'augmentation des niveaux de dépression chez les personnes amputées peut être associée à des dimensions d'adaptation de l'expérience émotionnelle de la déficience, plutôt que constituer en soi un simple signe d'inadaptation ou d'adaptation négative.

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Introduction

Lower-limb amputation results from a surgical procedure often performed because of a serious medical condition. Its most frequent cause is a vascular disease, often associated with diabetes mellitus and affecting mostly adults and elderly individuals (Moxey et al., 2010). Because of its potential functional and psychological implications, lower-limb amputation has been associated with emotional distress (Whyte and Niven, 2001; Darnall et al., 2005) and with well-being (Bosmans et al., 2007) and quality-of-life problems (De Godoy et al., 2002; Buzgová et al., 2009).

According to several studies (Whyte and Niven, 2001; Horgan and MacLachlan, 2004; Darnall et al., 2005; Atherton and Robertson, 2006), mood disorders such as depression and anxiety arise as common psychological reactions following amputation. Although some authors have found a lack of evidence for emotional distress after lower-limb amputation (Fisher and Hanspal, 1998; Oaksford et al., 2005), the majority of the literature is still at odds with this notion. According to previous studies using different measures (Jensen et al., 2002; Darnall et al., 2005; Atherton and Robertson, 2006; Singh et al., 2007, 2009), 13–30% of lower-limb amputees have depression.

In terms of the timing and duration of depression, although some studies in the literature have reported higher levels of depression during the first 2 years after the amputation (Horgan and MacLachlan, 2004), longitudinal studies have found a significant decrease in its incidence by the time the patient is discharged from the rehabilitation setting (Singh et al., 2007; 2009). Recent studies (Singh et al., 2007, 2009) have found a rapid resolution of depression and anxiety after patients have completed their rehabilitation programme. To explain the decrease in depression and anxiety levels, the authors highlighted the positive effect of rehabilitation on patients’ independence restoration, attributions to amputation and future outlooks. However, the majority of studies in the literature (Horgan and MacLachlan, 2004; Singh et al., 2007, 2009) have also shown that depression increases again between the second and the third year after limb loss and then tends to persist for a longer period of time.

In terms of the psychological variables leading to depression in amputees, some studies have found it to be linked to negative coping (Jensen et al., 2002; Sjödahl et al., 2004; Phelps et al., 2008), catastrophizing (Jensen et al., 2002; Hanley et al., 2004), existence of comorbidities (Singh et al., 2007; Coffey et al., 2009), and poor social support (Williamson et al., 1994; Williams et al., 2004). These variables have also been associated with a decrease in patients’ motivation and adherence to the rehabilitation programme, therefore compromising functional and autonomy recovery (Singh et al., 2007, 2009). However, positive coping appraisals of amputation are possibly associated with a better psychosocial adjustment to the impairment and with lower depressive levels (Couture et al., 2011). Notwithstanding, there is still a limited knowledge on the psychological variables that underlie the phenomenon of depression in amputees.

Studies by Malec and Moessner (2000) and Malec et al. (2007) on patients with orthopaedic injuries and traumatic brain injuries have found a strong relation between patients’ self-awareness of impairment and early, as well as late, depression following the physical impairment. These studies raised the hypothesis that self-awareness of impairment can be associated with emotional distress after impairment and therefore with the subsequent adjustment process.

A previous study that focused on the experience of lower-limb amputation in adult patients (Senra et al., 2012) found self-awareness of impairment and self-identification with the impairment to be the two core variables involved in the adults’ adjustment to the impairment. Nevertheless, there is no previous research targeting the study of the relationship between adults’ experience of amputation and depression levels.

The current pilot study aims to explore the relationship between the experience of lower-limb amputation and depression in a group of adult patients. Its main goal is to explore whether different adults’ experiences of amputation could be associated with different levels of depression. This study does not intend to search for any causal relationships or predictions for depressive levels, but rather to draw attention to the possible connections between the experience of amputation and depression. Such findings could shed some light on the topic and provide information for further large-scale epidemiologically sound studies.

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Methods

The current pilot study is part of a larger research project on adults’ adjustment to lower-limb amputation. That research had two objectives: to explore adults’ experiences of lower-limb amputation to identify the core themes related to those experiences and to explore the possible relationships between previously identified core themes in terms of the experience of lower-limb amputation and depressive levels. The first objective has been achieved and the findings have been published in a previous paper (Senra et al., 2012). The second objective is addressed in the current paper.

To fulfil the objectives of this research, a mixed-methods study with a convergent parallel design (Tashakkori and Teddie, 2010; Creswell and Clark, 2011) was used. In this design, the qualitative and quantitative data are collected concurrently, analysed separately and then merged (Creswell and Clark, 2011; Fig. 1). This methodological approach allowed basing the current study on the strengths of both methods (Creswell and Clark, 2011). Although the qualitative approach is useful for an in-depth understanding of the subjective phenomenon of patients’ experiences of limb loss, the quantitative method offers a less biased and a more generalized way of assessing patients’ depressive levels.

Fig. 1
Fig. 1
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Variables for the mixed-method design

The results obtained from the qualitative study, in terms of the first objective of this research, retrieved eight themes on the experience of lower-limb amputation (Senra et al., 2012). Five of the eight themes were identified as the patients’ core themes of the experience of amputation and were selected to be crossed with depressive levels in the current study (Fig. 1). The five themes were selected on the basis of two criteria: the relevance given to the themes by patients, on the basis of their perspectives of the experience of amputation and becoming an amputee; and whether the themes appeared in our previous adjustment model as being part of the main milestones of the adjustment process after amputation. The five selected themes and respective subthemes are as follows: self-awareness of impairment – subthemes ‘greater’ and ‘lower’ self-awareness; self-identification with the impairment – subthemes ‘greater’ and ‘lower’ self-identification; perceived social support – subthemes reported good or inadequate social support; and perceived well-being – subthemes with or without complaints of own well-being. Some examples of patients’ statements for each theme on the experience of amputation are presented in the previous paper (Senra et al., 2012).

According to the previous qualitative study (Senra et al., 2012), self-awareness of impairment was defined as the patients’ self-assessment of their new physical and functional condition. Patients with greater self-awareness of impairment reported a set of feelings and emotional reactions related to the amputation and also acknowledged its general implications. Patients with lower self-awareness of impairment minimized the general implications of the impairment, denying their situation and/or not considering the existence of any emotional reactions following amputation.

Self-identification with the impairment appeared in the previous study (Senra et al., 2012) as a reference to the patients’ identification (embodiment) with their new physical/functional condition and whether they perceived the amputation (new body) as being a part of themselves. Patients who strongly identified with their impairment reported a higher number of lifestyle changes related to the impairment; a better perception of the prosthesis and attributions related to it; and a higher level of adaptation in their social life and well-being.

In addition to the variables related to the experience of lower limb amputation, other variables such as type of amputation (transfemoral or transtibial); rehabilitation stage (ongoing or concluded); time elapsed since the amputation; and whether the patient is wearing a prosthesis, were also considered to cross with depressive levels, taking into account their potential influence on the experience of amputation.

All of the patients’ core themes and the variables related to the patients’ clinical histories were included to be crossed with our dependent variable: the depressive level (Fig. 1).

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Sample

The sample included 42 adult patients recruited from a Physical Medicine and Rehabilitation Department from a public general hospital. The inclusion criteria were as follows: a minimum age of 20 years at the time of the interview; amputation after the age of 20 years; amputation of a lower limb; and follow-up of the patients by the Rehabilitation Medicine Department. Ages were selected to avoid the interference of variables related to different developmental stages of life (childhood and adolescence). Patients who did not fulfil the inclusion criteria or had any confirmed cognitive, neurological or other serious medical condition were excluded as this could interfere with the patients’ outcomes. Patients in two different stages were considered: patients undergoing a rehabilitation programme for an average duration of ∼6 months and patients who had already been discharged from the rehabilitation programme and were then at a follow-up stage in which their health condition and functional progressions were being monitored. This rehabilitation setting included an overall programme of functional recovery, focused on enhancing patients’ daily life skills and on restoring their independence. During rehabilitation, patients were followed up by a specialized physician, a physical therapist and an occupational therapist. No systematic psychological or psychotherapeutic treatment was provided to the patients either during the rehabilitation period or after discharge as it was not a part of the formal clinical protocol. Ethical procedures were adopted following the institutional protocol, and informed consent was obtained.

The mean age in our sample was 61 years (minimum: 22; maximum: 82; SD=13.5), with a higher percentage of men (n=35; 83.3%). Most of the patients (n=25; 59.5%) had undergone amputation between the ages of 40 and 64 years. In total, 26 patients (61.9%) had undergone transtibial amputations and 16 patients had undergone transfemoral amputations. The main cause for the amputations was a vascular disease (83%). Twenty-nine patients had undergone an amputation up to 2 years before joining the research, whereas 13 patients had undergone amputation more than 2 years before joining the research. Half of the patients (n=21) were currently at a rehabilitation stage, following their rehabilitation programme, whereas the other half (n=21) were at a follow-up stage, after having concluded their rehabilitation. The average time that had elapsed between the amputation and the interviews was 8 months (SD=0.37 months; range from 2 to 24 months) in the group of patients currently undergoing rehabilitation and 3.9 years (SD=4.2 years; range from 1 to 17 years) in the group of patients at a follow-up stage.

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Data collection

The qualitative data on the experience of lower-limb amputation were collected by means of a semistructured interview [see Senra et al. (2012) for more details]. The patients’ depressive levels were assessed by the application of the Centre for Epidemiologic Studies Depression Scale (CES-D; Gonçalves and Fagulha, 2004). CES-D is a self-rating scale with final scores ranging from 0 to 60. A cut-off score of 23 was defined according to the Portuguese version of the CES-D (Gonçalves and Fagulha, 2004). Scores above 23 indicate clinical depression.

The assessment protocol to collect patients’ data involved two audio-recorded interviews per patient, lasting between 45 and 60 min. Interviewing patients two times instead of one facilitated their narratives about the subjective experience of amputation and allowed the collection of more data on that experience. Nonetheless, in a few cases, because of patients’ lack of willingness, we had to conduct the interview more than twice, until the protocol had been fulfilled. All interviews were conducted by a psychologist experienced in interviewing patients with physical impairments. A total of 85 interviews were conducted.

Ethical procedures were adopted following the institutional protocol, and informed consent was obtained.

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Qualitative data analysis

In the previous qualitative study (Senra et al., 2012), the qualitative data analysis was based on the thematic and categorical analysis proposed by Bardin (2008). In this method, an inductive analysis modality, using an open coding technique, was adopted (Guerra, 2006; Eto and Kyngäs, 2008) to avoid any previous ideas or conceptualizations about the participants. The main content analysis involved the following steps: transcripts were read at least twice, line by line, to infer their global and specific meanings and structures; each narrative’s specific meanings, which generated open codes (semantic criteria), were identified and labelled; codes sharing common themes were gathered; themes were reanalysed and reviewed to be labelled and regrouped into thematic categories; and thematic categories were validated by referring to transcripts. All of the coding procedures were performed independently by two researchers who held exhaustive discussions and focused on each meaning, and defined the criteria for each theme’s categorization during all steps of the analysis. The identification process of themes and categories resulted from the consensus between the researchers. Disagreements were solved by referring to transcripts.

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Statistical analysis

Considering the normal distribution with homogeneity of the variances of our dependent variable (depressive levels) between the groups analysed, parametric tests were used with a 95% confidence interval.

Pearson’s correlation test was used to correlate depressive levels with the time elapsed between amputation and the patients’ first interview.

The Student t-test was chosen to compare the mean scores of CES-D for each independent variable: type of amputation; rehabilitation stage; time elapsed between the amputation and the first interview; self-awareness of the impairment; self-identification with the impairment; wearing of a prosthesis; perceived well-being; and perceived social support.

Cohen’s d was used to determine the effect size (Henson, 2006). According to Cohen’s criteria, a d-value of ∼0.2 is considered to be a small effect; a d-value of ∼0.5 is considered to be a medium-sized effect; and a d-value of 0.8 or higher is considered to be a large effect.

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Results

The results of CES-D are presented in Table 1. As shown, 31% (n=13) of patients scored 23 or above on CES-D.

Table 1
Table 1
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No significant correlation was found between depressive levels (CES-D) and the time elapsed since amputation (0.84; P=0.595).

The Student t-test (Table 2) showed significant and nonsignificant differences in the CES-D scores between patients in different situations in terms of clinical history and experience of amputation, and the corresponding effect sizes. Cohen’s d showed a medium to large effect on self-awareness and a large effect on other variables for which significant differences in depressive levels were found.

Table 2
Table 2
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Discussion

The results of the current study suggest two main findings. First, our sample showed a similar frequency of depression (31%) when compared with the previous studies on this topic (Jensen et al., 2002; Darnall et al., 2005; Atherton and Robertson, 2006; Singh et al., 2007, 2009). Second, a significant association was found between the main variables related to the experience of amputation and depressive levels. Higher depressive levels were found in patients who reported greater self-awareness of impairment; lower self-identification with the impairment; inadequate social support; and poor well-being.

Although the sample size does not allow conclusion on any powerful extrapolation or cause–effect relationship between the variables studied, the results were sufficient to shed some light on the topic and to speculate on the possible factors that lead to depression. On the basis of the previous qualitative study and on the current results, this study suggests a comprehensive model for the way in which patients’ experiences of amputation could be associated with depressive levels (Fig. 2). In this model, it is proposed that greater levels of depression could be associated with three different dimensions of the adjustment process following amputation: patients’ confrontation with the impairment and their reported reactions on the experience of becoming an amputee; self-satisfaction, the patients’ current reports on their body image, well-being, and social support satisfaction; and patients’ embodiment of the new condition of becoming an amputee, in terms of their self-perceptions and in relation to the impairment.

Fig. 2
Fig. 2
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In the first dimension, the results are consistent with those of previous studies carried out by Malec and Moessner (2000) and Malec et al. (2007), in which a better and more realistic self-assessment of the impairment was found in patients with greater levels of depression. These findings shed some light on the initial increase in depressive levels after patients have undergone an amputation. When confrontation with the impairment and its implications lead to awareness of the current situation, instead of denial or minimization, patients realize that a set of losses are at stake. Depressive levels can therefore increase as an emotional response to a set of changes and losses in the functioning and autonomy of the patients’ own body.

The second dimension refers to patients’ current reports on their social support and well-being. Previous literature has shown how amputee patients’ poor quality-of-life perception (Asano et al., 2008; Mozumdar and Roy, 2010), well-being (Dunn, 1996; Mozumdar and Roy, 2010) and social support (Williamson et al., 1994; Rybarczyk et al., 1995; Williams et al., 2004; Mozumdar and Roy, 2010) can be strongly associated with depression. Some studies (Rybarczyk et al., 1995; Coffey et al., 2009) have also pointed out the potential impact of patients’ body-image anxiety on depression and emotional distress. The current study is in agreement with these suggested relationships and reinforces them, as, with the use of a different methodological approach in which patients’ outcomes derive from their own narratives, we have reached similar conclusions.

The third dimension of patients’ experiences of amputation is related to the embodiment process of the new life condition of becoming an amputee. Self-identification with the impairment reveals how patients are handling their impairment and its implications in their lives. The results suggest that patients who identified with their impairment to a lesser extent, and therefore handled it in a less adaptive way, manifested higher depressive levels. In contrast, patients with greater self-identification with the impairment appeared to have a more adaptive course and aimed at the resolution of depression, as they reported significantly lower depressive levels and a better functional restoration (Senra et al., 2012). These findings reinforce the previous assumption of considering patients’ self-identification with the impairment as a potentially important process in the adjustment process following amputation (Senra et al., 2012).

In terms of the effect of rehabilitation programmes on amputees’ adjustment, the previous literature has found them to be a positive factor in reducing depressive levels (Kent and Fyfe, 1999; Singh et al., 2007, 2009), along with psychological and psychotherapeutic interventions (Grobler, 2008; Hawamdeh et al., 2008; Rybarczyk et al., 2010). However, it is has also been shown that depression tends to reoccur after the patients’ discharge from the rehabilitation programme and it tends to become a long-term phenomenon (Hill et al., 1995; Behel et al., 2002; Horgan and MacLachlan, 2004; Singh et al., 2009). However, the main reasons for the chronic tendency of depression in amputees remain uncertain. Two previous longitudinal studies on the topic (Singh et al., 2007, 2009) have found correlations between long-term depression and two variables: manifesting symptoms of depression at the time of admission in a rehabilitation programme and having other comorbidities. The same studies have also not found any relationship between long-term depression and other factors such as age, sex, elapsed time since amputation, amputation level, vascular cause or wearing of a prosthesis. The current results are consistent with previous findings, as no associations were found between the sample’s demographic and clinical variables and depressive levels.

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Conclusion

The current findings raise the hypothesis of depression being associated with variables strongly related to the patients’ emotional expressions and experiences in terms of the amputation. This is logical, as depression is an emotional condition that is modulated by the individual’s emotional processes, such as emotional awareness, processing and experiences (Lumley et al., 2011). Previous studies have suggested that emotion-focused coping strategies are not proadaptive (Jensen et al., 2002; Phelps et al., 2008). In contrast, our study suggests a more positive role of emotions in the adjustment process to amputation. In agreement with recent psychological approaches (Nesse and Ellsworth, 2009; Lumley, 2010; Lumley et al., 2011), our study found a patient’s emotion to be a potential awareness facilitator and an experience processing promoter. In this way, our study suggests that depression could also be a part of the individual’s adjustment process, rather than being a mere sign of maladjustment or an inadequate coping strategy.

In terms of potential implications for clinical practice and further research, three suggestions can be presented in agreement with the current findings: to take into account patients’ emotional experiences of amputation along with the assessment of depression; to consider a long-term psychiatric and psychotherapeutic follow-up for these patients; to test the relationship between the experience of amputation and depression through a large-scale epidemiologically sound study, preferably with a longitudinal design.

In terms of our study’s limitations, first, because of the sample size and design of our study, the presented model for depression and the main results only reflect our patients’ perspectives. Therefore, it cannot be generalized to other samples without taking into account the inherent limitations of the current study. Second, because of the fact that our study is cross-sectional and not longitudinal, its findings do not confirm any causal relations or predictions for depressive levels and only present a preliminary view of the potential association between the experience of amputation and depression. Moreover, it was not possible to assess the patients’ evolution through time and to explore the inter-relationships between the significant variables.

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Acknowledgements

This work was supported by the Foundation for Science and Technology of the Portuguese Ministry of Science and Technology (http://www.fct.mctes.pt) through a 4-year grant award (ref: SFRH/BD/29987/2006).

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Conflicts of interest

There are no conflicts of interest.

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Keywords:

amputation; depression; experience; lower limb; mixed-methods; pilot study

© 2013 Lippincott Williams & Wilkins, Inc.

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