Improving Detection of Occult Depression in Chronic Limb Threatening Ischemia (CLTI) with a Customized CLTI-Specific Depression Screening Tool
Cuneyt Koksoy, Ilse Torres Ruiz, Xin Yee Ooi, Zachary S. Pallister, Ramyar S. Gilani, Joseph L. Mills, Jayer L. Chung
Baylor College of Medicine, Houston, TX
Introduction:Depression remains under-diagnosed in chronic limb-threatening ischemia (CLTI), with rare but devastating episodes of self-harm. However, despite its potential gravity, the relationship between depression and the severity of CLTI remains shrouded in uncertainty. We aim to develop a novel questionnaire customized to enhance diagnosis rates of depression in CLTI and quantify the associations of depression with CLTI severity.Methods:Two cross-sectional evaluations were performed on patients diagnosed and treated with CLTI from January 2023 to April 2023 (Group I) and May 2023 to August 2023 (Group II). In group I, only retrospective data of prior depression diagnosis, antidepressant use, age, sex, medical co-morbidities, ambulatory status, domiciliary status, socioeconomic variables, Wound, Ischemia, foot Infection (WIfI), and Rutherford scores were collected. In group II, In Group II, the same data was collected, along with our customized depression questionnaire, built based on validated questionnaires PHQ-9 and GAD-7. This questionnaire stratifies patients into minimal/mild depression (score < 30) versus moderate/severe depression (score > 30). Chi-squared and median (IQR) were used to describe the two groups, while linear regression was used to quantify associations between depression and CLTI severity.
Results:Over the study period, 101 CLTI patients (N=67, 66% male; median age 68 IQR 62-74 years) were evaluated. By retrospective chart review alone, 21.8% of patients were depressed. Depressed patients versus non-depressed patients were more likely to be active smokers (64% vs. 25%; p=0.001) and of Black race (46% vs. 24%; p=0.05). No associations were identified between WIfI score, Rutherford scores, marital status, domiciliary status, or socioeconomic variables and the severity of depression. Approximately 53% of patients had been previously screened for depression. When evaluating the questionnaire, there were no significant differences between Group I (N=58) and Group II (N=43) with respect to sex, ethnicity, medical co-morbidities, prior diagnoses of depression, current antidepressant use, illicit substance use, tobacco abuse, WIfI or Rutherford scores. In Group II, the median depression questionnaire score was 22 (IQR 19-33). Fourteen (32.5%) of group II patients were identified as moderate/severe depression, representing an increased detection of 10.7%. Within group II the moderate/severe depression CLTI patients versus the mild/moderate depression patients showed higher rates of non-ambulatory status (14.3% vs. 0%; p = 0.04) and prior history of depression (50% vs. 10.3%; p = 0.04). The median time to perform the questionnaire was 8 (IQR 6, 20) minutes.Conclusion:Our pilot data show that a rapid, CLTI-specific questionnaire increased the detection of depression by more than 10%. Depression affects approximately one-third of CLTI patients, but only half are screened. Depression was not associated with the severity of CLTI, socioeconomic variables, or gender. Non-ambulatory patients, prior history of depression, Black race, and tobacco abuse may be associated with increased rates of depression. Further prospective evaluation will be required to evaluate the efficacy of enhanced screening and treatment of depression upon vascular outcomes, as well as reducing episodes of self-harm.
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