A Prospective Longitudinal Study of Trajectories of Depressive Symptoms After Dysvascular Amputation

Abstract

Objectives: Characterize the course of depressive symptoms during the first year after dysvascular amputation and identify factors that predict symptom trajectories.

Design: Prospective cohort study of individuals undergoing lower extremity amputation (LEA), surveyed at 4 time points (perioperative period, 6 weeks, 4 months, and 12 months postamputation). Multilevel modeling was used to describe and predict trajectories.

Setting: Four Veterans Affairs medical centers, a university hospital, and a level I trauma center.

Participants: Participants (N=141; 74% retention) were a consecutive sample, eligible if they were undergoing their first unilateral LEA secondary to dysvascular disease.

Interventions: Not applicable.

Main outcome measure: Patient Health Questionnaire-9.

Results: Approximately 40% of participants endorsed at least moderate depressive symptoms at perioperative baseline. Individuals with greater depressive symptoms in the perioperative period concurrently reported greater pain, poorer self-rated health, and prior mental health treatment. In the first 6 weeks after amputation there was a substantial improvement in depressive symptoms, especially among individuals with greater symptoms at baseline. Depressive symptoms were generally stable after 6 weeks. None of the covariates assessed significantly predicted trajectories of depressive symptom improvement.

Conclusions: Watchful waiting may be the most appropriate course of action for many patients in the first 6 weeks after amputation. After 6 weeks, however, symptom levels tend to stabilize, suggesting that active intervention is called for if patients remain depressed at this point. Some patients may benefit from more proactive intervention, such as those with prior mental health treatment histories.

Keywords: Amputation; Depression; Rehabilitation.

Fig 1

STROBE diagram depicting participant flow. Abbreviations: STROBE, strengthening the reporting of observational studies in epidemiology.

Fig 2

Proportion of participant baseline and 12-month PHQ-9 sum scores, by symptom severity level.

Fig 3

Individual variability in slopes for time intervals (thick solid line represents fixed effect; thin dashed lines represent individual patient variation around the fixed effect).

Fig 4

Trajectories of depressive symptoms (PHQ-9 scores) during the first year postamputation: multilevel modeling analyses with (A) mental health treatment history; (B) presence of severe pain; and (C) SRH.