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What Impact Does Patient Mental Health Have On Podiatric Outcomes?

Could mental health issues be having an adverse effect on your patient’s treatment outcomes? In a revealing look at the literature, this author says podiatrists should have a strong awareness of potential psychological issues in their patients and emphasizes appropriate screening and referral when indicated.

Reportedly one in five adults in the United States experience a mental disorder at one point in their lives.1 Mental illnesses in adults are diagnosable disorders that negatively affect daily life activities.1 However, as per the National Survey on Drug Use and Health, less than 50 percent of adults in the U.S. with a mental illness received mental health services in 2012.1

Many patients with mental illness may not pursue specialty care with psychologists or psychiatrists because of perceived social stigmas. Additionally, in 2019, the organization Mental Health America stated that patients who wish to seek help are often not able to due to a national workforce shortage of mental health professionals with a reported ratio of one mental health provider in a state for every 504 patients with mental disorders.2 Furthermore, there is a lack of accessibility to mental health services for patients who cannot afford insurance. Out-of-pocket expenses can quickly add up when a patient needs several or constant visits for up to a lifetime.3

It is possible that podiatrists may be seeing patients who have undiagnosed mental health illnesses. The overall efficacy of podiatric treatment can be diminished due to a comorbid mental health condition, such as anxiety and depression. 

Accordingly, having a strong awareness of the signs and effects of mental health on the prognosis of lower extremity conditions may enable podiatrists to facilitate appropriate referrals to mental health providers and help improve overall health outcomes for these patients.4

When There Are Comorbid Psychological Disorders With Foot Disorders

Patients with symptoms of mental disorders approach foot disorders and recover from foot disorders differently than their counterparts without mental illness.5 In a randomized controlled trial (RCT), Nagakawa and colleagues found that approximately 30 percent of patients who visited a podiatric clinic with a chronic foot and ankle condition also had a previous diagnosis of clinical anxiety or depression.6 Through a multiple regression analysis examining the independent associations, the study authors found that psychological symptoms were associated with increased pain from foot and ankle ailments and a reduced quality of life.

In a 2010 randomized controlled trial involving people with diabetic peripheral neuropathy, Gonzalez and team found a significant association between depression and the development of a first foot ulcer but did not see this association with recurrent ulcerations.7 In another study, after controlling for other variables, Ismail and colleagues found that depression increased the risk of patient mortality three-fold over a year after the patient first presents with a diabetic foot ulcer.8 Furthermore, researchers have demonstrated that depression may be associated with the inadequate healing of foot ulcers.9 Depression also reportedly has negative effects on a patient’s immunity, neuroendocrine system, and vascular system.7 The research suggests that depression and lack of self-care are related to foot ulcer risk, so educating at-risk patients with depression who have not yet had a diabetic foot ulcer could prove beneficial in prevention.7

A retrospective cohort study by Williams and coworkers also showed a 33 percent increased risk for amputation in patients with both diabetes and depression.10 Peripheral arterial disease (PAD) that could ultimately lead to amputation is also associated with depression.5 In a retrospective review, Cherr and colleagues found that patients who had depression at the time of intervention for PAD had greater than 20 percent worse primary and secondary patencies at 24 months in comparison to patients without depression.5   

Possible reasons for these poor outcomes could stem from patients with diabetes not offloading or attending wound care appointments as instructed, given that depression is associated with poor diabetes self-care.10 After surgery, there is that possibility that amputations can lead to a negative body image. Amputations have functional and social implications that may impact patients’ lifestyles, including career choices and relationships. Again, these factors, in turn, may negatively impact healing and patients’ overall health post-amputation, so it is important to work with a mental health professional to help the patient navigate their emotions in a healthy manner before negative consequences arise in the lower extremity.10

When A Psychological Disorder Occurs As A Result Of A Foot Disorder

Foot disorders can affect a patient’s quality of life. Evidence from a structured interview that compared self-reported foot and leg problems to functional status showed that foot disorders lower the quality of life of older patients along with additional physical, social, and mental challenges.11 

In a 2016 study involving 102 people with hallux valgus, Lopez and coworkers found that over 38 percent of the study participants had depression as measured by the Beck Depression Inventory (BDI).12 Patients with a greater degree of hallux valgus showed an increase in depression based on BDI scores with a score above 9 and below 29, indicating mild to moderate depression. 

Depression is also reportedly linked to diabetic peripheral neuropathy.13 Postural instability from muscle weakness may lead to the inability of patients with diabetic peripheral neuropathy to perform tasks previously expected of them, reducing their self-confidence.13 Some of these patients may become more immobile, which can result in more comorbidities from physical inactivity. Some lose the will to follow the steps prescribed for diabetes control.13 

In a case-control study by Fejfarova and colleagues, about 5 percent of patients with diabetic foot complications had suicidal tendencies due to the constant requirements for therapy, the complications, and the longevity of the condition.14 The study authors suggest that counseling patients about the various benefits from therapy and the positive aspects of each step of the treatment and guiding them along the way with someone to hold them accountable can help.

In a 2010 prospective study involving 93 participants with diabetic foot ulcers, Vedhara and team obtained salivary samples to measure cortisol and wound fluid samples to measure matrix metalloproteinases (MMPs).15 The study authors found that excessive levels of MMP-2 hindered healing. Representing connective remodeling and inflammation, MMP-2 and MMP-9 influence the rate of healing for ulcers. Excessive levels in salivary cortisol are indicative of increased stress. Cortisol is regulated by the hypothalamic-pituitary-adrenal axis activity which downregulates immunity.15 Without being able to use effective coping mechanisms to deal with depression, participants in the study showed less improvements in wounds.15

What About Perioperative Considerations Related To Mental Health Challenges?

Before foot and ankle surgery, if patients are experiencing associated pre-surgery anxiety, there may be negative impacts on the healing process. Patients awaiting surgery worry about potential post-surgical consequences. Furthermore, inadequate self-care before the surgery can add to the pre-operative anxiety.16 Stress can also cause increased glucocorticoids, decreasing IL-1 and TNF-alpha production. These cytokines help the tissue repair process in remodeling the damaged tissue and activating more phagocytic cells. Increased glucocorticoid levels in patients with diabetes can increase blood glucose levels, worsening wound healing and contributing to more DFUs.16

The decrease in the immune response in podiatric patients leads to a repeating cycle of stress.17 Knowing their immune response is diminished, the patients’ stress progresses. Natural killer cell activity (NKCA) normally removes cells that no longer function properly through apoptosis. Immediate post-surgical elevations in stress reduce natural killer cell activity through an unknown mechanism which otherwise would have promoted a quicker recovery.17

The stress-mediated response can cause a greater need for anesthesia and post-surgery pain medication along with other post-surgery recovery challenges.18 It is common for a post-amputation patient to display anxiety and depression symptoms for months after. Patients may feel they are no longer in control and are afraid of the unknown. The mental health symptoms come from the fear of pain and losing mobility, or from a decreased body image socially and professionally.18

Pertinent Keys To Mental Health Screening, Recommendations And Appropriate Referral 

According to a study done in 2003 by Crews and colleagues, patients who have a mental illness have four to 11 times the amount of podiatric disorders than the general population.19 It could simply be due to the neglect of self-care and not a direct association. The study authors contend that these patients encounter providers who are unfamiliar with treating this population, and this results in the provided healthcare being inadequate.19 Again, having a strong awareness of signs and symptoms of those possibly having mental illness may facilitate appropriate referrals and enable podiatrists to address related hurdles that may impact treatment of lower extremity issues.

Relative to the rest of the podiatric patient population, patients with conditions related to diabetes are more likely to have already exhibited symptoms of anxiety and depression.18 As a result, patients with diabetes have a poorer overall prognosis. They may fear the consequences of diabetes or, if they have diabetic foot ulcer, the intensive medical regime may increase their anxiety and depression symptoms.18 Patients may give less importance to their self-care due to poor medication compliance, diet, and foot care. They may feel that they are unable to control their diabetes regardless of their actions or may feel overwhelmed due to the steps required for their treatment. This sense of being overwhelmed may also be exacerbated by wound care-related pain or chronic pain from arterial insufficiency, infection, osteomyelitis, and painful neuropathy.18

An optimal solution would be to start by offering a more holistic approach to podiatric patients.20 Podiatrists can remind patients about the importance of social support and coping mechanisms. In amputation cases, working with a mental health professional to offer the amputee psychological support can touch upon the various aspects of the amputee’s well-being and healing after the surgery.20 The approach can help ensure a better outcome and help with mobility, as patients will maintain their sense of autonomy.21 Various modalities would include improving safety through teaching patients how to tackle physical instability, increasing the feeling of competence and, if necessary, the use of antidepressants, prescribed by a mental health professional. The therapy may also help the patient be more prepared for surgery.13

As for treating other podiatric patients who are not having amputations, other avenues of psychological monitoring and support may be beneficial in certain cases. Podiatrists can help by providing educational information and materials relevant to addressing mental health concerns. A few options to include in the resources for anxiety management could be information about brief and inexpensive cognitive behavioral therapy with imagery, relaxation training, and coping activities.22 Podiatrists can hand out pamphlets detailing progressive muscle relaxation, options for physical activity, mental balance, and nutrition. Incorporating these interventions and offering contact information of accessible mental health professionals may help lower the risk of all podiatric patients from developing ulcers by reducing the levels of anxiety through the physiological process I detailed above.22

Psychological, social, and environmental challenges have the potential to prevent re-integration into the lifestyle the patient had before they had lower extremity issues.18 If one addresses a patient’s environment, including the presence of a caregiver, family interactions, and social support, then the treatment outlook can be more positive.18 In addition, tailored multidisciplinary steps, including adequate physical therapy, counseling and pain relief, can help prevent long-term disability.18 Another approach is biofeedback-assisted relaxation training which increases peripheral perfusion and has shown positive outcomes in healing patients with chronic non-healing ulcers.23

In Conclusion

The need to address psychological symptoms to facilitate optimal treatment of podiatric patients is not well known. With more training and awareness about this subject, podiatry professionals can be well-equipped to alleviate symptoms and help patients gain the necessary tools to help themselves. Therefore, further research on the particular methods to do so effectively would be beneficial for not only patients but for overall health-care costs, as well. There is an emerging consensus from the aforementioned studies that a multidisciplinary approach to psychological and social issues may improve health outcomes in patients. As a result, podiatrists can be significant allies for patients in recognizing potential mental health issues and ensuring appropriate referral to mental health professionals.

Ms. Mohapatra is a third-year student at the California School of Podiatric Medicine at Samuel Merritt University.

Online Exclusives
By Diksha Mohapatra, BS

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6. Nakagawa R, Yamaguchi S, Kimura S, et al. Association of anxiety and depression with pain and quality of life in patients with chronic foot and ankle diseases. Foot Ankle Int. 2017;38(11):1192-1198.

7. Gonzalez J, Vileikyte L, Ulbrecht J, et al. Depression predicts first but not recurrent diabetic foot ulcers. Diabetologia. 2010;53(10):2241-2248. 

8. Ismail K, Winkley K, Stahl D, Chalder T, Edmonds M. A cohort study of people with diabetes and their first foot ulcer. Diabetes Care. 2007; 30(6):1473-1479.

9. Monami M, Longo R, Desideri CM, Masotti G, Marchionni N, Mannucci E. The diabetic person beyond a foot ulcer: healing, recurrence, and depressive symptoms. J Am Podiatr Med Assoc. 2008;98(2):130-136.

10. Williams L, Miller D, Fincke G, et al. Depression and incident lower limb amputations in veterans with diabetes. J Diabetes Complicat. 2010; 25(3):175-182.

11. Barr E, Browning C, Lord S, Menz H, Kendig H. Foot and leg problems are important determinants of functional status in community dwelling older people. DisabilRehabil. 2005;27(16):917-923.

12. Lopez D, Fernandez J, Iglesias M, et al. Influence of depression in a sample of people with hallux valgus. Int J Ment Health Nurs. 2016;25(6):574-578.

13. Vileikyte L, Peyrot M, Gonzalez J, et al. Predictors of depressive symptoms in persons with diabetic peripheral neuropathy: A longitudinal study. Diabetologia. 2009;52:1265-1273.

14. Fejfarova V, Jirkovska A, Dragomirecka E, et al. Does the diabetic foot have a significant impact on selected psychological or social characteristics of patients with diabetes mellitus?. J Diabetes Res. 2014; 2014:371938.

15. Vedhara K, Miles J, Wetherell M, et al. Coping style and depression influence the healing of diabetic foot ulcers: observational and mechanistic evidence. Diabetologia. 2010;53(8):1590-1598.

16. Christian L, Graham J, Padgett D, Glaser R, Kiecolt-Glaser J. Stress and wound healing. Neuroimmunomodulation. 2006;13(5-6):337-346.

17. Starkweather AR, Witek-Janusek L, Nockels RP, Peterson J, Mathews HL. Immune function, pain, and psychological stress in patients undergoing spinal surgery. Spine. 2006;31(18):E641-647.

18. Pedras S, Carvalho R, Pereira M. A predictive model of anxiety and depression symptoms after a lower limb amputation. Disabil Health J. 2018;11(1):79-85.

19. Crews C, Vu K, Davidson A, Crane L, Mehler P, Steiner J. Podiatric problems are associated with worse health status in persons with severe mental illness. Gen Hosp Psychiatry. 2004;26(3):226-232.

20. Hofmann S, Asnaani A, Vonk I, Sawyer A, Fang A. The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognit Ther Res. 2012;36(5):427-440.

21. Hawamdeh Z, Othman Y, Ibrahim A. Assessment of anxiety and depression after lower limb amputation in Jordanian patients. Neuropsychiatr Dis Treat. 2008;4(3):627-633. 

22. Taha F, Lipsitz J, Galea S, Demmer R, Talley N, Goodwin R. Anxiety disorders and risk of self-reported ulcer: a 10-year longitudinal study among U.S. adults. Gen Hosp Psychiatry. 2014;36(6):674-679.

23. Rice B, Kalker A, Schindler J, Dixon RM. Effect of biofeedback-assisted relaxation training on foot ulcer healing. J Am Podiatr Med Assoc. 2001;91(3):132-141.

Additional Reference

24. Rodriguez-Sanz D, Tovaruela-Carrion N, Lopez-Lopez D, et al. Foot disorders in the elderly: A mini review. Dis Mon. 2018;64(3):64-91.


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