- Chronic wounds often have a negative impact on general quality of life and sense of well-being in patients.
- Depression in patients with chronic wounds is prevalent and often not communicated by patients themselves.
- Patient well-being is often overlooked in wound assessment protocols focused on the local wound bed only.
- Routine depression screening and evaluation of various psychosocial factors should be a part of assessment for all patients with chronic wounds.
Wounds with a duration longer than 30 days are considered chronic. For example, diabetic foot ulcers comprise a large majority of these wounds and often exceed the expected 12-week healing period because of underlying factors that cannot be fully corrected.1 Patients with chronic wounds face considerable psychological stress because they need continuous medical care and frequent visits to healthcare facilities. The presence of these wounds significantly disrupts the daily life of patients, including changes in sleeping patterns, diet, and mobility. Loss of mobility may lead to feelings of loneliness, powerlessness, and dependency, as patients rely on family or friends to help fulfill their basic needs such as commuting, activities of daily living, and personal hygiene. Further, patients may experience chronic pain, exudate, and odor, which negatively impact social interactions, relationships, sexuality, and self-confidence. All of these psychosocial factors add up and may lead to a slow onset of anxiety and depression in patients with chronic wounds. Further, healthcare providers have a tendency to overlook the fact that these components have a direct effect on the ability of a wound to heal completely.
The link between chronic wounds and depression was highlighted by House and Hughes2 in 1996. Numerous studies since then3,4 have confirmed that depression has adverse effects on wound healing outcomes. This is mostly attributed to poor adherence to treatment, resistance to lifestyle changes, and inadequate communication between the patient and provider regarding well-being. In particular, patient depression leads to pessimism regarding perceived treatment benefits and subsequently lowers self-efficacy. This vicious cycle may result in poor self-care and wound hygiene, as well as nonadherence to medication regimens or regular wound care requirements such as dressing changes.5
Healthcare providers involved in wound care are advised to adopt the biopsychosocial model6 and should be aware of the negative impact of social and psychological factors on wound healing.1 The biopsychosocial model, first proposed by George Engel7 in 1977, suggests that it is not sufficient to manage only biologic factors (wound/wound pathology); holistic treatment must also address the psychological factors (thoughts/emotions, distress, coping methods) and social factors (family circumstances, work issues, socioeconomic and cultural parameters) affecting the patient.
An often-neglected part of chronic wound management is the assessment, evaluation, and management of depression in these patients. It is essential that providers are on the lookout for subtle signs of mood disorders (Table) and initiate a psychological assessment as part of the holistic management plan. Many well-validated and simple-to-administer depression rating scales exist; the Patient Health Questionnaire-98 is one option that is freely available to any healthcare provider (https://www.mdcalc.com/phq-9-patient-health-questionnaire-9).
SUBTLE SIGNS OF DEPRESSION AND ANXIETY IN PATIENTS WITH WOUNDS
|Mood and composure
||Sadness, visible tension, irritability, resistance to change
||Excessive sleep or lack of sleep, lethargic, slow reactions
||Loss of appetite or sudden weight gain
|View of future
||Hopelessness; loss of interest, self-confidence, and/or joy; futile life outlook; and nonadherence to treatment
||Frequent memory lapses, difficulty in task completion
Based on this assessment, patients with suspected depression should be referred for appropriate mental health interventions as part of the interprofessional team approach in the management of wounds.
Providers should help patients with chronic wounds understand that their wounds do not constitute a complete setback in life but represent a new challenge that requires adaptation. Although all change is difficult, professional assistance may be necessary for patient support and motivation to seek help, especially if the patient also has comorbid depression. Timely interventions for depression and other mental health issues will enhance outcomes for all patients with chronic wounds and are an integral part of the wound assessment process.
1. Sibbald RG, Elliott JA, Persaud-Jaimangal R, et al. Wound bed preparation 2021. Adv Skin Wound Care 2021;34(4):183–95.
2. House A, Hughes T. Depression and physical illness. Prescr J 1996;36:222–8.
3. Zhou K, Jia P. Depressive symptoms in patients with wounds: a cross-sectional study. Wound Repair Regen 2016;24:1059–65.
4. Fino P, Di Taranto G, Pierro A, et al. Depression risk among patients with chronic wounds. Eur Rev Med Pharmacol Sci 2019;23(10):4310–2.
5. Steel A, Reece J, Daw AM. Understanding the relationship between depression and diabetic foot ulcers. J Soc Health Diabetes 2016;4:17–24.
6. Borrell-Carrió F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med 2004;2(6):576–82.
7. Engel G. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129–36.
8. Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatr Ann 2002;32(9):509–15.