Understanding Diabetes-Related Extremity Amputation Depression & Distress (DREADD)
A Breakthrough in Podiatry-Mental Health Research
A Breakthrough in Podiatry-Mental Health Research
The World Health Organization (WHO) reports a substantial increase in individuals living with diabetes from 200 million in 1990 to 830 million in 2022, with a more rapid increase observed in low- and middle-income countries (LMICs) compared with high-income countries.1 The impact of type 2 diabetes mellitus (T2DM) extends beyond metabolic dysfunction, significantly affecting brain insulin resistance (IR), which can impair mood and cognition and is implicated in neurodegenerative processes including amyloid-beta metabolism and tau phosphorylation.1 Globally, approximately 28% of individuals with T2DM experience depression of varying degrees, with 14.5% meeting the criteria for major depressive disorder.1 A bidirectional relationship between T2DM and depression likely arises from shared etiological factors such as hypothalamic–pituitary–adrenal (HPA) axis dysregulation, inflammation, hippocampal structural alterations, and weight gain.1
It is known that both T2DM and depression are leading causes of disability despite T2DM being largely preventable and depression being among the most treatable mental health conditions.1 Of the roughly 38 million people diagnosed with type 2 diabetes mellitus in the United States, up to 34% will develop a diabetic foot ulcer at some point, up to 75% of those who develop an ulcer will experience recurrent ulcers, and approximately 18% of patients with a diabetic foot ulcer will undergo lower-limb amputation.2 This ends up being more than 86,000 Americans with T2DM who undergo nontraumatic lower-extremity amputations annually.3 Further complicating this issue, including the postoperative course, is the uncomfortable fact that a minor, nontraumatic amputation, which is still the loss of part of the body even if “only a toe,” can be a traumatic experience for patients.2
Looking at the Literature Thus Far
From 2023 to 2025, my brother Bradley M. Brooks, DO, and I have produced 4 publications on the intersection of diabetes and depression by collaborating with some of the brightest minds in podiatric medicine and surgery. Our first publication is a foundational podiatry-mental health publication that tackles the association between the following variables: diabetic foot complications, depression, and opioid use.3 In this retrospective cohort study, we coined the term “the Diabetic Foot–Pain–Depression Cycle” (Figure 1) and noted that antidepressants can be protective against prolonged opioid use following forefoot amputation.3
Of note, our Journal of the American Podiatric Medical Association (JAPMA)–published article has been cited by researchers across the world (Poland, Saudi Arabia, China, etc.) for its insight into improving post-amputation care and offering the “multidirectional direct-indirect causation hypothesis” between diabetes mellitus and depression.3 Dr. David G. Armstrong and I would expand upon this article by co-authoring a chapter by invitation from the 48th Annual Northwestern Vascular Symposium.
Building off the first publication, our second publication would propose that depression is a risk factor contributing to amputation.4 We looked at the prevalence of depression in the veteran population and utilized the Veterans Administration’s (VA’s) PAVE (Preventing Amputation in Veterans Everywhere) program, which uses PAVE foot risk scores (FRS) ranging from 0 to 3.4 The prevalence of depression was noted to have no statistical difference between PAVE FRS 2 (No amputation or DFU; neuropathy can be present) and 3 Veterans (DFU or Amputation); however, both FRS 2 and FRS 3 had greater odds of having a documented diagnosis of depression compared to FRS 0 (FRS 0 represents the lowest risk tier).4
Further, Figure 2 highlights a steady increase in depression prevalence as the FRS increases.4 Given that depression can be a problem before amputation, we recommended further research on the inclusion of depressive symptoms into existing classification systems for threatened limbs and DFUs.4 Further, we proposed a modified threatened limb classification system that accounts for depression in the veteran population (Figure 3).4
Our third publication took a deep dive into the patient experience following an amputation, and we also compared Patient Health Questionnaire 9 (PHQ-9) scores before and after amputation (no more than 30 days apart).2 The PHQ-9 is one of the most common ways to screen for depression.2 In this study, we used both quantitative and qualitative methodology to characterize the attitudes of patients with T2DM toward their nontraumatic, minor amputation. Starting with the qualitative aspect, we chose semistructured in-person interviews to enable patients to further describe their experiences (Table 1).2
Looking at the study’s quantitative aspect, 20 patients met the inclusion criteria for the retrospective cohort, and of those 20 patients, 90% (18 of 20) had increased PHQ-9 scores within 30 days of their toe amputation or partial ray resection.2 The mean PHQ-9 score before amputation was 3.65. The mean PHQ-9 score after amputation was 12.35. The difference in the mean before and after PHQ-9 scores was 8.7 (P =.0001); a representation of these scores appears in Figure 4.2 We coined the term Diabetes-Related Extremity Amputation Depression & Distress (DREADD), which is a novel form of depression that can begin following an amputation.2 While depression is always pathologic, distress is more akin to “burnout” for patients with T2DM and may not always rise to the level of “pathology,” but it can still impact the postoperative course in terms of adherence and self-care.2 In simple terms, diabetes distress is emotional distress that comes from the burden living with diabetes and daily self-management that can overwhelm patients especially if the “value” of adherence to the treatment plan cannot be easily conceptualized or appreciated.
How Can Podiatrists Intervene?
The recommendations of the first 3 studies are clear. Given that depression remains underdiagnosed and patients with T2DM are commonly seen by podiatric physicians and surgeons, those podiatric physicians and surgeons should screen for depression preoperatively via the Patient Health Questionnaire (PHQ)-2 and the PHQ-9.2-4 The purpose of the PHQ-2 is to screen for depression in a “first-step” approach.3 If the patient scores 3 or more, then the podiatric physician should administer the PHQ-9.3 On the PHQ-9, scores of at least 5 indicate mild depression, 10 reflects moderate depression, 15 for moderate-severe depression, and 20 for severe depression.2-4 Podiatric physicians and surgeons should make the appropriate mental health referral if there is a concern for depression; personally, I always make the referral with a score of 10 or more and I go case-by-case for scores 5 to 9.2-4
Screening for depression has several practice implications for the podiatric physician and surgeon; screening for depression, along with documenting a follow-up plan, is a “preventative care and screening measure” for the Merit-based Incentive Payment System (MIPS) program (measure #134).3-4 A referral to a mental health specialist, such as a psychiatrist or a clinical psychologist, fulfills the follow-up plan requirement and should be documented in the note. Although podiatric physicians should focus on screening preoperatively to avoid a delay in care, it is recommend that podiatric surgeons screen for depression postoperatively if postoperative opioid use extends beyond 7 days following uncomplicated toe amputations in patients with altered epicritic and protopathic sensation.3-4
Final Thoughts
Our fourth publication was a literature review focused on need for the emergence of “Diabetes Psychiatry,” as well as deep dive into the association between depression and T2DM. The historical recognition of the interplay between diabetes and mental health dates back to the 17th century when Thomas Willis linked diabetes to “lasting melancholy.”1 While the connection has been acknowledged for centuries, it has only recently garnered significant scientific attention, with research increasingly highlighting the complex ways in which these conditions influence each other.6,7
As comorbid depression has such a profound effect on diabetes management and outcomes, the importance of having integrated psychiatric care as part of diabetes management is increasingly being understood. Polypharmacy is common in T2DM due to the need for metabolic control and complication management.1,8 Treating depression in T2DM is crucial; however, polypharmacy risks complicate prescribing decisions.1,8
The ultimate recommendation of the fourth study, and of this article, is that podiatric physicians and surgeons should consider bringing in psychiatrists and other mental health clinicians as members of multidisciplinary limb preservation teams given that existing healthcare guidelines recommend the use of antidepressants for moderate-to-severe depression (PHQ-9 scores of 10 or more).1,5 By becoming advocates for not only our patients’ lower extremity health, but also their mental health, podiatrists have unique and deeply impactful opportunities to improve outcomes across a broad health spectrum.
Dr. Brooks is the current Treasurer of the American College of Podiatric Medicine and the creator of ACPM’s Journal Club Notebook. As a Diplomate of the American Board of Podiatric Medicine, he holds a Certificate of Added Qualification in Podiatric Surgery. From 2019 to 2020, he served as the APMA’s 6th Public Health Fellow at the Geisel School of Medicine at Dartmouth in Hanover, NH, where he received the Masters Award. His research has won 1st place at several conferences: Desert Foot 2022, The American Podiatric Medical Association National conference 2023, and the American Society of Podiatric Surgeons’ conference in 2024. Dr. Brooks is a staff podiatrist at the Columbia VA Health Care System in Columbia, SC.
Published in partnership with the American College of Podiatric Medicine
For further reading on better understanding and promoting mental and emotional health in podiatric patients, see “Words Matter: The Impact of Stigmatizing Language in Healthcare Documentation” in the June 2025 issue of Podiatry Today, the October 2024 article, “How Do Depression and Distress Affect Surgical Outcomes in Diabetic Amputation?,” the March 2024 blog, “Why We Need to Have Affective Empathy for Our Patients,” the December 2023 interview, “How Neuropathy, Pain, and Depression Can Lead to Amputation,” “Does Identification of Diabetes Distress Improve Outcomes?” from October 2024, the June 2023 Diabetes Watch column, “How Do Adverse Childhood Experiences Impact Diabetes and Its Complications?,” or the June 2023 blog, “The Final Frontier for the Podiatric Surgeon-Scientist: Multidisciplinary Research Teams.”
You can also browse previous Diabetes Care Theme Issues at https://shorturl.at/ETZ2y, https://shorturl.at/2g99J, or https://shorturl.at/lhFKL.
References
1. Brooks BM, Nettles AM, Brooks BM. Diabetes psychiatry: the missing piece of the puzzle to prevent complications of the diabetes pandemic. Psychoactives. 2025; 4(2):13. https://doi.org/10.3390/psychoactives4020013
2. Brooks LM, Brooks BM, Arp AS, et al. Diabetes-Related Extremity Amputation Depression and Distress (DREADD): a multimethod study. Semin Vasc Surg. 2025;38(1):94-100. doi: 10.1053/j.semvascsurg.2025.01.002.
Epub 2025 Jan 23. PMID: 40086927.
3. Brooks BM, Shih CD, Brooks BM, et al. The Diabetic Foot-Pain-Depression Cycle. J Am Podiatr Med Assoc. 2023;113(3):22-126. doi: 10.7547/22-126. PMID: 37463195.
4. Brooks BM, Banks J, Arp AS, et al. Depression: the fourth pillar of classifying risk of diabetes-related amputation in veterans. J Psychiatry Psychiatric Disord. 2023;7(6):201-209
5. Jeffery A, Maconick L, Francis E, et al. Prevalence and characteristics of antidepressant prescribing in adults with comorbid depression and type 2 diabetes mellitus: A systematic review and meta-analysis. Health Sci Rev (Oxf). 2021;1. doi: 10.1016/j.hsr.2021.100002. PMID: 35028650; PMCID: PMC8721955.
6. Akhaury K, Chaware S. Relation between diabetes and psychiatric disorders. Cureus. 2022;14(10):e30733. doi: 10.7759/cureus. 30733. PMID: 36447711; PMCID: PMC9699801.
7. Goldney RD, Phillips PJ, Fisher LJ, Wilson DH. Diabetes, depression, and quality of life: a population study. Diabetes Care. 2004;27(5):1066-70. doi: 10.2337/diacare.27.5.1066. PMID: 15111522.
8. Guthrie B, Makubate B, Hernandez-Santiago V, Dreischulte T. The rising tide of polypharmacy and drug-drug interactions: population database analysis 1995-2010. BMC Med. 2015;13:74. doi: 10.1186/s12916-015-0322-7. PMID: 25889849; PMCID: PMC4417329.
