The evaluation of patients with diabetes includes conventional aspects of history and concomitant conditions along with a thorough review of laboratory tests. However, there are important aspects of diabetes mellitus that are often not screened, undertreated and, in some cases, lead to profound morbidity and mortality. Depression and suicidality have a high prevalence among those with diabetes and are significantly associated with a variety of diabetes-related complications.1
It is important to note that not all patients with diabetes will develop every complication nor will these complications always be present in end-stage status. Some patients may have mild retinopathy while others will suddenly become blind. Some patients will have mild renal insufficiency while others may progress to end-stage renal disease with the need for dialysis.
Specifically, diabetic peripheral neuropathy predisposes patients to ulcerations, soft tissue and osseous infection and sepsis. These complications put this particular cohort with diabetes at increased risk for limb loss. Patients with acute infections often require multiple surgical interventions and have frequent hospital readmissions. A slow downtrend with suboptimal glycemic control often results in a progressive and
cyclical pathology. In cases of non-healing ulcerations or surgical sites, patients become inundated with the extensive outpatient management of both the wound and their systemic diseases.
For those with mobility limitations and weightbearing restrictions, frequent follow-ups and wound care instructions can become obvious barriers to selfcare. One of the single most important independent markers for developing major depression from any health-related disorder is becoming dependent on others to complete daily functional tasks. Dependence, or the loss of independence, is a strong driver for major depression.2 Patients who require amputations related to diabetes fall into this category. One should note that both a partial fifth toe amputation and an above-the-knee amputation can be similarly profound losses to the patient. Some patients come to terms with amputations easily while others suffer inner turmoil and severe mental anguish at the diagnosis alone. The duration of related wound care, followup appointments and dependence on others to aid in daily functional activities cumulatively results in exacerbation of an already high prevalence of depression in the diabetic population.
Outcomes may be similar in patients with diabetes, whether the depression is newly diagnosed or has been diagnosed in the past. In fact, some studies suggest several overlapping biochemical and genetic predispositions shared between those with depression and those with diabetes.3 Nonetheless, the virtues and discussions of what came first, the chicken or the egg, is not of clinical relevance. Patients diagnosed with complications of diabetes must indeed undergo screening for signs and symptoms of major depression as well as suicidality.
It may not require much probing to screen for and diagnose major depression. However, suicidality becomes more elusive. The most common presentation in the surgical patient is a phenomenon known as passive suicidality. This is best explained in comparison to active suicidal ideation. Patients with active suicidal thoughts will usually tell you some plan and have a way to act on their thoughts. This is alarming and requires immediate corrective action. Those who display passive suicidality may not have a plan to end their life but may, even unknowingly, decline or postpone life-saving treatments as this will result in the same fate.
I have sadly witnessed patients who require hemodialysis but refuse this treatment. I have also seen patients who refuse lifesaving surgery for necrotizing infection. However, more subtle forms of this passive suicidality exist, such as delay tactics while one’s condition declines. Proper screening for major depression can help clinicians identify patients who are at
high risk for this form of suicidality.
There are several available tools and metrics that one can employ to screen patients for both major depression and suicide risk, including the Patient Health Questionnaire-9 (PHQ-9).4 I will concede that patients can be very elusive and scores can be cumbersome to tally. In short, my goal is to increase awareness and lower the threshold for interaction with our behavioral health specialists as well as involving ethics teams early on to ensure these patients get a high level of medical care provided in a compassionate manner.
Overall, health outcomes for patients with diabetes require a collaborative and all-inclusive approach. Mental health challenges are complex and it becomes the responsibility of all providers at every level to exercise due diligence in the care of patients at risk for under-recognized diseases like depression.
Dr. Elmarsafi is a fellowship-trained attending physician who is affiliated with the Department of Plastic Surgery at Georgetown University Hospital and Washington Hospital Center in Washington, D.C.
1. Elamoshy R, Bird Y, Rhorpe L, Moraros J. Risk of depression and suicidality among diabetic patients: a systematic review and analysis. J Clin
2. Fisk A, Wetherell JL, Gatz M. Depression in older adults. Annu Rev Clin Psychol. 2009;5:363-389.
3. Badescu SV, Tataru C, Kobylinska L, et al. The association between diabetes mellitus and depression. J Med Life. 2016;9(2):120-125.
4. The Joint Commission Suicide Prevention Workgroup. Suicide prevention. Available at: https://www.jointcommission.org/resources/patient-safety-topics/suicide-prevention/. Published 2018. Accessed August 28,2020.