Prevalence and correlations between suicide attempt ...

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Prevalence and correlations between suicide attempt, depression, substance use, and functionality among patients with limb amputations Pedro I. Arias Vázqueza, Rosa G. Castillo Avilaa, Mayra del C. Dominguez Zentellaa, Yazmín Hernández-Díazb, Thelma B. González-Castrob, Carlos A. Tovilla-Záratea, Isela E. Juárez-Rojopc, María L. López-Narváezd and Ana Frésane Most patients undergoing limb amputations suffer significant emotional changes. The aim of this study was to estimate the prevalence of suicide attempts and depression in a sample of Mexican patients with limb amputations and, second, to determine whether the patients’ functionality correlates with the presence of depression. We studied 40 patients who had undergone a limb amputation. The suicide attempt was evaluated using the Suicide Intent Scale. The depression was assessed using the Hamilton Depression Rating Scale, whereas the functionality of the patients was measured using the Functional Independence Measure. In this sample, 90% were men, whereas only 10% were women. In terms of the suicide behavior, we identified suicide attempts in 27.5% of the patients. The rate of depression was 92.5%. In the Functional Independence Measure, we observed that 57.5% of the patients showed complete dependence. Finally, a significant correlation was found between depression and functionality (r = − 0.75, P < 0.001). The findings of the present study highlight the high incidence of suicide attempts and depression in Mexican patients with limb amputations. Also, we identified a correlation between the lack of functional independence

Introduction The surgical removal of a lower or an upper limb (amputation) is a life-changing procedure and often considered the last option when all treatments have failed; however, because of medical advances, the number of survivors has increased (Aulivola et al., 2004; Desteli et al., 2014). This procedure is indicated in patients with failed attempts of revascularization and the typical indications of amputation include trauma, infections, and neoplasms (Aulivola et al., 2004; Stern et al., 2017). Diabetes mellitus is the most common cause for nontraumatic lower-extremity amputations; peripheral neuropathy, infection, ulceration, and peripheral vascular disease are the principal factors for ulcer complications and loss of a lower limb in diabetic patients (Pscherer Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website, www.editorialmanager.com/ijrr. 0342-5282 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

and depression. Therefore, holistic interventions are necessary in these patients: rehabilitation therapy to increase their functionality, and psychological and pharmacology therapy to decrease suicidal behavior and depression. Finally, more studies using larger samples are necessary to obtain conclusive results. International Journal of Rehabilitation Research 00:000–000 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. International Journal of Rehabilitation Research 2017, 00:000–000 Keywords: amputation, depression, suicide a Autonomous University Juarez of Tabasco, Multidisciplinary Academic Division of Comalcalco, Comalcalco, bAutonomous University Juarez of Tabasco, Multidisciplinary Academic Division of Jalpa de Méndez. Jalpa de Mendez, c Autonomous University Juarez of Tabasco, Academic Division of Health Sciences. Villahermosa, Tabasco, dGeneral Hospital of Yajalón, Health Secretary, Yajalon, Chiapas and esubdirection of clinical investigations, National Institute of Psychiatry Ramón de la Fuente Muñíz, Mexico, Mexico

Correspondence to Carlos A. Tovilla Zárate, PhD, División Académica Multidisciplinaria de Comalcalco, Ranchería Sur, Cuarta Sección, C.P. 86650, Comalcalco, Tabasco, México Tel: + 52 993 358 1500 x6900; e-mail: [email protected] Received 11 August 2017 Accepted 21 September 2017

et al., 2012; Quilici et al., 2016). The aim of an amputation is to save the patient’s life; however, it is a catastrophic procedure that will have a major impact on the patients’ quality of life and can be emotionally devastating for them (Sahu et al., 2016; Mattiassich et al., 2017). Approximately 1.6 million individuals in the United States suffer from limb loss, of whom 541 000 individuals present an upper limb loss. It is estimated that 30 000 traumatic amputations occur each year and it is projected that the number of individuals living with the loss of a limb will double by the year 2050 (Ziegler-Graham et al., 2008). Individuals with an amputation are at risk of developing depressive symptoms and suicide. By itself, suicide is a significant public health issue with a multifactorial pathogenesis, whereas depression has been established as the strongest psychopathological predictor of suicidal ideation (Indu et al., 2017; Wang et al., 2017). Although the relationship between depression and DOI: 10.1097/MRR.0000000000000259

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suicide is still controversial, some studies have found that depressive symptoms predict suicidal ideation accurately, suggesting a close link between depression and suicide (Sahu et al., 2016; Wang et al., 2017). Similarly, alcohol abuse/dependency and cigarette smoking are among the few risk factors identified for suicidal ideation, suicide attempts, and suicide (Hufford, 2001; Hooman et al., 2013). Reliable information on the prevalence of suicidal attempts, depression, and substance use is important to design programs for the prevention, treatment, and the identification of emotional distress causes. Quantification of function is a basic tool for monitoring the progress of patients during treatment; it provides a standard, valid, and reliable assessment that helps to compare populations and treatment efficacy (Ring et al., 1997). Although other countries have published studies on the psychological effects of amputations (Hawamdeh et al., 2008; Mosaku et al., 2009; Turner et al., 2015), in Mexico, there is a significant lack of information on the prevalence of suicide attempt and depression among Mexican patients with limb amputations and on their functional status. The aims of this study are (a) to explore the prevalence of comorbidities (suicide attempt, depression, and substance use) in patients with a limb amputation; (b) determine the level of physical functioning of patients; and (c) correlate clinical characteristics with depression or functionality in a Mexican population.

Patients and methods Patients

Patients between 17 and 71 years of age were invited to participate. The final sample comprised 40 patients who had one or more limb amputations (lower and upper). This study was carried out in the High Specialty Hospital ‘Dr Gustavo A. Rovirosa Pérez’ and the Rehabilitation Center and Special Education located in Tabasco, Mexico. The study was carried out from January 2016 to January 2017. Ethics statement

All the patients who underwent a limb amputation were invited to participate. All patients received oral and written explanations that included the objectives of the study. Only patients who provided and signed the informed consent were included in the present study. The patients did not receive any economical remuneration. The study was approved by the local ethics committee of the High Specialty Hospital ‘Dr Gustavo A. Rovirosa Pérez’ (HR/DEEI/0124/16).

income, in which socioeconomic group do you belong to? low (earn 1–5000 USD), medium (earn 5001–10000 USD), and high (earn > 10 000 USD). Additional information on the amputation characteristics, substance use, and suicidal attempts was collected using open-ended interview questions. Suicide attempt: Suicide attempt was evaluated form the moment the patients were informed that they were going to have a limb amputated until the moment of the study (after of the limb amputation). We used the Suicide Intent Scale in the Spanish version for a confirmation of suicide attempt (Beck et al., 1974). The Hamilton Depression Rating Scale (HDRS). To evaluate depression in the amputee patients, we used the HDRS, which is one of the most widely used scales to assess depression; it has 17 items, each rated from 0 to 4, for a total score of 0–52, and the higher the score, the higher level of depression (Ramos-Brieva and Cordero-Villafafila, 1988; Lobo et al., 2002). Scores above 7 indicate depression, and the severity of depression was graded as follows: not depressed (0–7 points), mild (8–13 points), moderate (14–18 points), severe (19–22 points), and very severe (>23 points) (Hamilton, 1960). Functional Independence Measure (FIM). To determine the level of physical functioning in the amputee participants, the FIM (Stineman et al., 1997) was used, which includes 18 activities of daily living, measured on a seven-level scale. Level 1 indicates complete dependence and level 7 indicates complete independence. The values obtained can range from 18 to 126 points (96). The patients are classified as having complete dependence when they score 31–63 points (25–50% independent), partially dependent with 63–94 points (50–75% independent), and independent when their score is between 94 and 126 points (75–100% independent). Statistical analysis

Frequencies and percentages were calculated for the qualitative variables; mean and SD were calculated for the quantitative variables. Correlations between the clinical characteristics of the amputation and depression or functionality were also calculated. We used the Pearson correlation coefficient for the quantitative variables and Spearman’s correlation for the ordinal qualitative variables. A P-value of less than 0.05 was considered significant.

Results Sociodemographic and clinical data

Sociodemographic characteristics

A semistructured data sheet was used to collect the sociodemographic information. It included marital status, years of education, socioeconomic level, and occupation. The socioeconomic level was measured using the question ‘according to your perception and your annual

The sample consisted of 36 (90%) men and four (10%) women, between 17 and 71 years of age (mean = 39.30, SD = 14.31). Most patients (70%) were single and on average the patients had secondary education (mean = 6.9, SD = 3.68). The most frequent socioeconomic level


Suicide among individuals with amputations Arias Vázquez et al. 3

was low (85%) and, finally, 47.5% were unemployed at the time of the study (Table 1).

15.25 ± 3.28 years; also, 35% of patients used nicotine and the age of onset was 17.50 ± 5.54 years (Table 2).

Clinical characteristics

Prevalence of suicide attempt, depression, and functionality

Of the 40 amputee patients included in our study, the most common amputation was of a lower limb (65%) and the patients were evaluated 12.22–23.79 weeks after the amputation surgery. Trauma and consequences including work injury and puncture wounds accounted for 65% of the amputations, followed by vascular insufficiency in 32.5% (Table 2). The most commonly substance used among patients was alcohol (85.7%), with an age of consumption onset of 16.91 ± 5.41 years. Cannabis use was observed in 20% of patients and age of onset was

Table 1

Sociodemographic data of the patients studied

Sociodemographic data

Mean ± SD (range)/n (%)

Age (years) Years of education Males Marital status Single Married Widower Socioeconomic level High Medium Low Occupation Unemployed Home Student Part-time employment Full time employment

39.30 ± 14.31 (17–71) 6.9 ± 3.68 (2–17) 36 (90)

Table 2

28 (70.0) 9 (22.5) 3 (7.5) 1 (3.5) 5 (12.5) 34 (85.0) 19 1 1 7 12

We looked for differences in the HRDS score and functional independence between alcohol abusers; however, we did not observe any differences between groups (Supplementary Table A1, Supplemental digital content 1, http://links.lww.com/BPMJ/A46). Equally, no statistical differences were observed when we compared the HDRS values and FIM between patients who attempted suicides and patients who did not (Supplementary Table S2, Supplemental digital content 1, http://links.lww.com/BPMJ/A46). Correlation between the level of functionality and the level of depression

(47.5) (2.5) (2.5) (17.5) (30.0)

Finally, we looked for a correlation between the clinical characteristics of the amputation and depression or functionality. We found a significant correlation between functionality and depression (r = − 0.75, P < 0.001) (Table 3).

Discussion

Clinical data of the patients studied n (%)

Characteristics of the amputations Location Upper limb Lower limb Etiology Vascular insufficiency Trauma and sequel Infections Number of amputations One Two More Substance use Alcohol Cannabis Nicotine Comorbidity Suicide attempt Depression Functionality Independent Partially dependent Fully dependent Hamilton Depression Rating Scale score Functional Independence Measure score

Of the 40 amputees, 27.5% attempted suicide (n = 11); among these, two patients died of suicide during the time of this study. When the presence of depression was evaluated, 92.5% of the amputee patients were found to have depression. The level of functionality of the amputee patients was classified using the FIM scale and we observed that 57.5% of the patients presented complete dependence. Table 2 shows the prevalence of mood disturbances and the level of functionality in the patients included in the study.

14 (35.0) 26 (65.0) 13 (32.5) 26 (65.0) 1 (2.5) 33 (82.5) 6 (15.0) 1 (2.5) 35 (87.5) 8 (20.0) 14 (35.0)

The present study estimated the prevalence of comorbidities and determined the functionality of patients in a sample of Mexican amputees. The study also examined the correlation among clinical characteristics and the level of functionality, and the severity of symptoms of depression. Our study shows that young males in our population were the ones who more often undergo amputations. This was expected, and is similar to other reports (Padovani et al., 2015; Gopinathan et al., 2017). In terms of clinical aspects, the main causes of amputation were trauma and its sequels. We also observed that the Table 3

Correlations of depression levels and functionality Depression

11 (27.5) 37 (92.5) 5 12 23 37.90 59.27

(12.5) (30) (57.5) (13.85) (28.22)

Variables Time since amputation Location Etiology Functionality

r-value − 0.25 − 0.06 − 0.17 − 0.75

P-value 0.11 0.69 0.28 < 0.001

Functionality r-value

P-value

0.27 0.03 0.09

0.08 0.82 0.55

Values in bold are significant.


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amputation of a lower limb (65%) was most common, similar to the results obtained by other authors (Lim et al., 2006; Penn-Barwell, 2011; Nunes et al., 2014). Posture stability is usually compromised in individuals with lower-limb amputation and this causes an increased risk of falling (Vanicek et al., 2009; Barnett et al., 2013). The etiology of the amputations has an effect over the balance and postural stability; for example, (Molina-Rueda et al., 2017) not only reported that patients with unilateral transtibial amputation have reduced stability in comparison with patients without amputations, but that the cause of amputations influences postural stability as vascular unilateral transtibial amputee patients showed better balance than those who had a nonvascular (including trauma) etiology. In our study, the incidence of suicide attempts was 27.5%. This incidence of suicides was higher than that observed in other populations; for instance, in the USA, amputee patients show a suicidal ideation prevalence of 15.71% (Turner et al., 2015). As expected, our data confirm that suicide attempts are more frequent in patients with a limb amputation than in the general population of Tabasco. However, the general population of Tabasco has high rates of suicide attempts (6.2%) (Fresan et al., 2016; Gonzalez-Castro et al., 2016; Reyes-Tovilla et al., 2016), confirming that amputations trigger suicide behavior, clearly indicating that is necessary to implement prevention programs against suicide behavior in Tabascan amputees, particularly those with trauma etiology, as the amputations are usually emergency procedures, whereas preventive actions in vascular cases are needed before and after the surgical intervention. In terms of depression, in Mexico, the prevalence is 4.5% (Belló et al., 2005), whereas in our amputee group, it reached 92.5%. This frequency of depression in amputees is also higher than that observed in other countries such as India, where 72.7% incidence of depression was reported in amputees (Bhutani et al., 2016). However, the literature shows that the type of amputation is related to the level of depression (Yilmaz et al., 2016). In our study, 65% of the amputations were nonvascular – post-traumatic, which could explain why the frequency of depression was higher than that in other populations (Ide, 2011; Mckechnie and John, 2014; Restrepo et al., 2014; Sahu et al., 2016). About 50–80% of amputees experience phantom limb pain; those who experience it show higher incidence of depression, indecisiveness, suicidal ideation, and other thoughts of self-harm (Richardson et al., 2006; Rostaminejad et al., 2017; Yin et al., 2017). Therefore, we suggest that psychological and pharmacologic therapies are necessary to decrease the severity of depression symptoms and decrease suicide attempts; moreover, nonpharmacological treatments including Eye Movement Desensitization and Reprocessing could be an option to alleviate phantom limb pain (Rostaminejad et al., 2017).

In Mexico, the rate of consumption of alcohol throughout life is 71.3% (Medina-Mora et al., 2012). In our amputee sample, we observed higher rates (85.7%) of alcohol consumption, which could suggest that amputations per se could have triggered the alcohol consumption/abuse; nevertheless, according to our evaluation of the onset age of alcohol consumption, these patients had been consuming alcohol for long time before the amputations, and more likely, the alcohol intake only increased after limb loss (Cornelius et al., 1995; Handley et al., 2016). An important aspect was the patients’ functionality. We observed that 57.5% of the patients presented complete dependence and a correlation was found between functionality and the severity of depression symptoms (r = −0.75, P < 0.001). This suggests that the lower the functionality, the more the depression. Some studies suggest that the levels of depression in amputee patients can be reduced by the use of prosthesis (or by improving the aesthetic aspect of their prosthesis) (Desteli et al., 2014; Ladlow et al., 2015), and thus improving the functionality of these patients. Equally, being under pharmacological treatment for depression can improve the functionality of the patients (Norvell et al., 2011). Then, rehabilitative and pharmacological therapies are necessary to increase the functionality in patients with limb amputation. We recognized some limitations in our study. First, we had a relatively small number of participants; however, there are other studies with a sample size similar to that of the present study (Bhutani et al., 2016). Second, depression was not diagnosed through psychiatric examinations, but with the use of the HDRS scale. Third, prosthesis use was not investigated. We consider that the evaluation of psychiatric symptom associated with prosthesis use should be performed in future studies. Conclusion

This study showed a high prevalence of suicide attempt, depression, and diminished functionality in patients after a limb amputation. Although the medical objective of an amputation is to save patients’ lives, we need to keep in mind that this is an event that alters negatively, in general, the quality of life and even the perception of the patient’s own life. Functional dependence, pain, and their own body experience may trigger depression and suicide thoughts. During rehabilitation, the caregivers should always be empathic to the patients; furthermore, rehabilitation programs should also consider what the patients are going through after the amputation. The new programs should involve hospitals, general practitioners and carers; therefore, in case depressive symptoms arise, the patients could receive a promt mental treatment, preventing further complications (suicide ideation or suicide attempts). It is therefore a clear target for hospitals to change carers’ perspective, which should also understand the amputees’ needs and life perspectives; thus, caregivers and the different clinicians who work


Suicide among individuals with amputations Arias Vázquez et al. 5

with them (physiatrists, surgeons, nurses, psychologists, and so on) can improve the amputees’ quality of life. Finally, more studies using larger samples are necessary to obtain conclusive results.

Acknowledgements The authors gratefully thank all the patients who participated in this study. Conflicts of interest

There are no conflicts of interest.

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