How Depression And Anxiety Affect Patient Adherence
Finally, Broadbent studied the effect of stress on surgical wound healing by analyzing wound fluid for the levels of specific cytokines and used regression analysis to quantify the effect of stress on those levels. The study correlated perceived stress with lower levels of IL-1 and MMP-9, indicating that stress impairs the inflammatory responses and matrix degradation processes that one sees in the early stages of normal wound healing.12
In addition to an increased incidence of anxiety and depression, patients with diabetes also face cognitive and behavioral impairments related to the effect of prolonged hyperglycemia on the brain. Specifically, diabetes impairs hippocampus-dependent memory, perforant path synaptic plasticity and adult neurogenesis.13
Hyperglycemia triggered excesses of the adrenal glucocorticoids appear to play a role in these adverse effects.14 Impaired hippocampal synaptic plasticity ultimately results in impaired cognitive and behavioral functioning.13,14 Additionally, oxidative stress and reactive oxygen species are increased in patients with diabetes and both reduce the activity of a variety of proteins that are crucial to neuronal homeostasis.15
Strategies For Improving Patient Adherence
Recognizing these less frequently discussed complications of diabetes suggests several ways we can strengthen our practices. Now more than ever, we must insist on tight glycemic control. No diabetic patient should ever leave our office without at least two staff members asking about the patient’s most recent hemoglobin A1c. Patients failing to achieve the American Diabetes Association (ADA) 2009 target of 7 or lower need to hear how critical it is to lower their levels. Explaining the damaging effect of hyperglycemia on brain function should now be a part of that discussion. One should also refer these patients to diabetes support services and encourage them to pursue new glycemic control strategies with their primary care provider.
Secondly, as much as we would rather leave it up to primary care, we should screen our patients for depression and anxiety. There is a significant under-detection of these disorders among primary care physicians, and the majority of individuals with depression and anxiety do not access effective treatment.16 When it comes to this under-detection among primary care physicians, many of us may be affected by provider perceived stigma concerning emotional issues and the avoidance of asking questions for fear of harming the relationship.16 The link between emotional illness and poor wound healing behooves us to get past our discomfort and develop a non-threatening, expeditious way to screen for the problem.
There are several accurate depression and anxiety screening tools available that use a quick self-assessment questionnaire. One can distribute these tools at patient registration and a staff member can score them before one sees the patient.17,18 The Hospital Anxiety and Depression Scale (HADS) and the Generalized Anxiety Disorder (GAD-7) scale are two such tools that have been used effectively in primary care settings.17,18
Incorporating these screening tools in our office protocols also makes a clear statement to our patients that we understand chronic wound healing requires attention to psychological as well as physical health. By modeling behavior that destigmatizes and stresses the importance of mental health, and by insisting on tight glycemic control, we have an opportunity to make real progress with our patients with diabetes.
Ms. Megas is a nurse practitioner with the Center for Wound Healing at Georgetown University Hospital in Washington, DC.
Dr. Steinberg is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. Dr. Steinberg is a Fellow of the American College of Foot and Ankle Surgeons.