Common Mental Disorders in Patients Undergoing Lower LimbAmputation: A Population-based Sample

Marco Antonio Nunes • Newton de Barros Jr. •

Fausto Miranda Jr. • Jose Carlos Baptista-Silva

Published online: 24 February 2012

� Societe Internationale de Chirurgie 2012

Abstract

Background Amputations result in a variety of limita-

tions that have emotional consequences for patients. The

aim of the present study was evaluate non-psychotic dis-

orders and their associated factors in a sample of people

with lower limb amputations.

Method A cross-sectional study was conducted that

assessed the association of sociodemographic and clinical

variables in relation to psychiatric disorders evaluated

through the Self Reporting Questionnaire (SRQ-20) for

patients undergoing lower limb amputation. The associa-

tion between the outcome of the SRQ-20 and the other

variables was assessed with the chi-square and Student’s

t test; to explore the magnitude of association adjusted for

covariates, a logistic regression model was developed.

Results One hundred-thirty eight (138) patients were

interviewed, and a prevalence of 43% (60/138) was

observed for patients with mental disorders assessed with

the SRQ-20 questionnaire. We also observed that male

patients (p = 0.017) and those who were married (p =

0.035) had a lower rate of psychological problems; those

who were not considered independent (p = 0.036) and

those with a greater number of morbid conditions

(p = 0.036) showed a higher positivity in relation to

psychological morbidity (p = 0.003). Logistic regression

analysis showed that only the associated chronic diseases

(p = 0.0328) and lack of independence (p = 0.0197)

remained significant.

Conclusions Given the high prevalence of mental disor-

ders related to the number of associated morbid conditions

and to the situation of dependency among lower limb

amputees, the psychological and social assessment of these

people is recommended, in addition to encouraging their

self-care and the return to their activities.

Introduction

Lower limb amputations are common and inevitable in the

practice of any surgeon who cares for patients with

peripheral vascular disease [1, 2]. These procedures result

in a variety of limitations of activities that lead to depen-

dence on others. Thus these patients face the obvious

physical challenges, as well as an array of emotional and

social difficulties, as do their families and the service

personnel that assist them [3]. Lower limb amputations

have significant associations with depression, anxiety,

social discomfort, and changes in body image that may be

related to a high morbidity [4].

Given the importance of the psychosocial component in

the health of people and the growing interest in assessing

the perception of the well-being of individuals and com-

munities, in the sense of enhancing broader parameters for

controlling symptoms, the World Health Organization

developed the Self Reporting Questionnaire (SRQ-20).

This is a psychiatric screening instrument for studies in

community and primary health care, and is especially

useful in developing countries, because it is a low-cost

assessment tool that is quick and easy to apply [5].

By defining the factors that might influence the welfare

of people with lower limb amputation, it may be possible to

M. A. Nunes (&)

Department of Medicine, Federal University of Sergipe,

Rua Claudio Batista s/n, Av Aniseo Azevedo, 351,

apto 502, Aracaju, SE 49.020-240, Brazil

e-mail: manprado@uol.com.br

N. de Barros Jr. � F. Miranda Jr. � J. C. Baptista-Silva

Department of Surgery, Federal University of Sao Paulo,

Rua Borges Lagoa, 754, Sao Paulo, SP, Brazil

123

World J Surg (2012) 36:1011–1015

DOI 10.1007/s00268-012-1493-4

establish the best strategy of care, provide a more efficient

service, suggest actions that may result in a longer survival

after lower limb amputation, and plan focused programs

directed at achieving a better quality of life for the patients,

their families, and their caregivers.

The present study aimed to evaluate non-psychotic

disorders in a sample of people with lower limb amputa-

tions in a community and the factors associated with this

situation.

Materials and methods

Type of study

A cross-sectional study was conducted from 1 January to

31 December 2008. The research was planned in accor-

dance with the Declaration of Helsinki and approved by the

Ethics in Research Committee with the protocol number

588 on 14 December 2006. To begin, the patients were

identified by primary health care teams in the city of

Aracaju, Sergipe, in northeast Brazil. After each patient

provided informed consent, data were collected through

visits to their residences, and the relevant data were

recorded on a standardized form.

Sample

Inclusion criteria were as follows: individuals undergoing

unilateral or bilateral lower limb amputation at the levels of

thigh, leg, foot, or toe; etiology related to trauma, diabetes

mellitus, infection, ischemia, or cancer; and if the time

since amputation was more than six months, to create a

situation of stability in which the variables could be

judged. Criteria for exclusion were as follows: individuals

who had mental retardation or dementia that precluded

participation. Regarding the calculation of sample size, it

was assumed that the variable containing the response of

interest had a proportion of the population of 24.95% [6], a

maximum error of estimate of 8%, with a significance level

5%. Thus the sample size of 113 individuals was calcu-

lated, and, assuming a risk of loss of 20%, the sample

volume was estimated at 139 patients.

Variables and instruments

The survey form consisted of sociodemographic data such

as age, gender, and marital status; clinical variables, such

as etiology, level of amputation (major related to leg and

thigh and minor to foot and toe, using the ankle as the

reference limit); time since amputation; and number of

associated morbid conditions recorded in the referred to

form (systemic arterial hypertension, diabetes, heart and

kidney diseases, bronchitis or emphysema, asthma, stroke,

arthritis, cancer, and changes in vision). In addition, par-

ticipants were asked about the implementation of basic and

instrumental activities of daily living and were classified as

dependent when they reported needing help to perform at

least one of these activities [7].

The Self Reporting Questionnaire instrument is com-

posed of 20 questions designed to track psychiatric disor-

ders in primary health care [8] in its Brazilian version has

been previously validated [9]. The items of the SRQ-20

were recorded dichotomously (yes or no) to obtain a score

ranging from 0 (no probability) to 20 (extreme probability)

related to the probability of the presence of non-psychotic

disorders; the results were reported dichotomously as either

cases or non-cases by a cutoff point of 7/8 in which B7:

negative score; C8: positive score indicating psychoemo-

tional illness. The questionnaire was completed in the

course of an interview lasting an average of seven minutes,

and all questions were read aloud by a researcher previously

trained for the presence of illiterate people in this sample.

Statistical analysis

Descriptive analysis was performed using the absolute and

relative frequencies in the case of categorical variables and

through measures of central tendency and variability in the

case of numerical variables. We evaluated the association

between clinical and sociodemographic variables and the

risk of psychoemotional illness through the result of the

SRQ-20; differences between proportions were tested with

the chi-square test or Fisher’s exact test, and for analysis of

the comparisons of the mean of two independent samples, the

statistical Student’s t test for association was used.

Then, we conducted a logistic regression analysis to

control variables of confusion, using the ones that showed

significant association, with the aim of exploring the

magnitude of association between sociodemographic and

clinical variables and the results of the SRQ-20, adjusted

for covariates to identify potential predictors of mental

disorders. Odds ratio was calculated, adjusted with its

respective confidence interval of 95% (95% CI). In all

analyses, two-tailed tests were used that were considered

significant if p was less than 0.05.

Results

Of the 139 individuals with lower limb amputation in the

sample selected, one person had mental impairment and

therefore we interviewed 138 patients. The mean patient

age was 62.3 years (95% CI 62.3 ± 2.71), with 57% (78/

138) males and 49% (67/138) married; the mean time since

amputation was 4.3 years, ranging from six months to

1012 World J Surg (2012) 36:1011–1015

123

28 years. Regarding associated diseases, 14% (19/138)

reported none, 70% (97/138) had diabetes mellitus, and

69% (96/138) had systemic arterial hypertension.

As for the evaluation of mental disorders conducted

through the SRQ-20, 43% (60/138) of the patients were

considered positive. This instrument also identified, among

the demographic variables (Table 1), that the male ampu-

tees (p = 0.017) and those who are married (p = 0.035)

had a lower rate of mental health problems. In turn, those

who were not considered independent by the hierarchical

scale of disability (Table 2) showed a positive score in

relation to psychological morbidity (p = 0.003).

We also compared the mean time since amputation and

the number of associated diseases in relation to the results

of the SRQ-20 and observed that people with a shorter time

since amputation and with a greater number of associated

morbid conditions had a higher possibility of presenting

psychological disorders (Table 3).

Given these results, logistic regression analysis was

applied to the data (Table 4). The association between the

observed dependent and independent variables showed that

only the associated chronic diseases (p = 0.0328) and the

independence (p = 0.0197) assessed by the hierarchical

scale of disability were significant. The analysis of the

measurement of association performed using the odds ratio

is represented in Table 5.

Discussion

Emotional disturbances were present in fewer than half of

the amputees evaluated. Through estimates by other

instruments, the following were observed: prevalence of

anxiety 29.9% and depression 13.4% in a sample of people

with lower limb amputations [10] and psychological dis-

orders in 40% of the amputees in a specialized ambulatory

clinic [11]. In contrast, the results of population surveys in

Brazil revealed an estimate of emotional disorders in

24.95–28.5% of this patient population [6, 12, 13].

The logistic regression model revealed an association

between the number of reported illnesses and psychologi-

cal problems in the adjustment of the patients. This sug-

gests that the impact of chronic diseases on people’s lives

should be evaluated and monitored, as such problems tend

to remain with an individual throughout life and can affect

different organs and systems. It has also been shown that

chronic diseases are negatively associated with a person’s

state of mental health [14, 15]. In older people this effect

was proportional to the number of diseases, with the

presence of two or more of them having a significant

negative effect [16].

Another aspect that influenced the emotional, psycho-

logical aspects of the amputee patient was independence in

carrying out basic and instrumental activities of life. This

may be associated with the presence of pre-existing chronic

diseases [2, 17] and can affect survival, as it has already

been demonstrated that loss of function is a predictor of

mortality [17]. The inability to move, even partially, can

impair social interactions [18], leaving the patient isolated

and, consequently, with depressive symptoms [19], causing

discomfort and placing a burden on their families [20].

The importance of this research was to have shown that

a significant number of patients who undergo lower-limb

amputations are not referred to rehabilitation units,

although such units are available. Thus the amputees have

difficulties adapting to their environment. This situation

may be similar to that for patients in other centers, and it

should be corrected because the dependency and social

restriction strongly influence the life of these patients.

Studies have shown that the rehabilitation process should

be implemented before the operation and sustained until

the final adjustment of the prosthesis, thereby allowing the

patients to regain autonomy, and return to their usual

activities [2, 21–23]. The results have shown that being

able to perform basic functions allows a return to com-

munity life that is enhanced by the aesthetic function of the

prosthesis and has an important influence on psychosocial

adaptation to this procedure.

Table 1 Relation between

mental disorders assessed by the

SRQ-20, gender, age, and the

fact of being married or not

* Significant at p \ 0.05,

chi-square

Variable SRQ-20 Total p Value

No Yes

Gender

Male, n (%) 51 (65%) 27 (35%) 78 0.017*

Female, n (%) 27 (45%) 33 (55%) 60

Age group

\64 years, n (%) 37 (54%) 31 (46%) 68 0.622

[65 years, n (%) 41 (59%) 29 (41%) 70

Married

No, n (%) 34 (48%) 37 (52%) 71 0.035*

Yes, n (%) 44 (66%) 23 (34%) 67

World J Surg (2012) 36:1011–1015 1013

123

The present study showed that female patients presented

a positive score in the screening for psychological disor-

ders, a situation that has been reported by several authors

[13, 24]. This may be associated with a stronger propensity

toward anxiety and depression [4]. The same score was

seen with patients who were unmarried and with those with

a shorter time since amputation; however, these factors lost

their statistical significance with multivariate analysis.

The mental morbidity has been studied in a population

of amputees, but the selection of patients in most studies is

performed by extraction of amputees from database and

medical records [20, 23], or through rehabilitation centers

[3, 10, 18] and outpatient clinics specializing in amputa-

tions [11, 19]. The choice of selection method may have

introduced important selection biases because, as most

patients were elderly and had associated diseases, many of

Table 2 Relation between

mental disorders assessed by the

SRQ-20 and the level of

amputation, the time since

amputation, the etiology, and

the fact of being independent

or not

* Significant at p \ 0.05,

chi-square

Variable SRQ-20 Total p Value

No Yes

Level of amputation

Minor, n (%) 27 (59%) 19 (41%) 46 0.716

Major, n (%) 51 (55%) 41 (45%) 92

Time since amputation

\35 months, n (%) 34 (49%) 35 (51%) 69 0.086

[36 months, n (%) 44 (64%) 25 (36%) 69

Etiology

Not chronic, n (%) 21 (64%) 12 (36%) 33 0.345

Chronic, n (%) 57 (54%) 48 (46%) 105

Independence

No, n (%) 60 (51%) 57 (49%) 117 0.003*

Yes, n (%) 18 (86%) 3 (14%) 21

Table 3 Relation between the

SRQ-20 result and the mean

time since amputation and the

number of associated diseases

* Significant at p \ 0.05,

Student’s t test

Variable SRQ-20 No. patients Mean Standard deviation p Value

Time since amputation No 78 61.1 69.0 0.036*

Yes 60 40.6 43.5

Associated diseases No 78 2.0 1.3 0.005*

Yes 60 2.7 1.6

Table 4 Result of logistic

regression analysisVariable Estimate Standard error W test p Value R

Gender 0.6006 0.4001 2.2533 0.1333 0.0366

Marital status 0.7057 0.4017 3.0868 0.0789 0.0758

Associated diseases 0.293 0.1373 4.5558 0.0328* 0.1163

Independence 1.5711 0.6739 5.435 0.0197* 0.1348

Time since amputation -0.0056 0.004 2.0058 0.1567 -0.0056

Table 5 Association measured

by odds ratio and confidence

interval

Variable Odds ratio 95% CI of odds ratio

Minimum Maximum

Gender 1.8232 0.8323 3.9938

Marital status 2.0252 0.9217 4.45

Associated diseases 1.3404 1.0242 1.7542

Independence 4.812 1.2844 18.0284

Time since amputation 0.9944 0.9867 1.0022

1014 World J Surg (2012) 36:1011–1015

123

them were not sent to a rehabilitation center. For this

reason, we decided to collect a sample directly from the

community and through home visits in order to reduce the

risk of systematic errors and to obtain better external

validity. For these reasons, our findings can be generalized

to other centers with more security.

Because many of these patients had low education and

were illiterate, it was not possible to use complex and self-

applied questionnaires. We therefore chose a simple

instrument, the SRQ-20, which allowed the tracking of

minor mental disorders such as depression, anxiety, and

neurotic and psychosomatic symptoms, and that was easily

understood and quickly applied through an interview [5, 8].

Therefore this study showed that access to the health

system should be designed to follow the patient whose limb

has been amputated. Although amputation it is commonly

considered the end of a therapeutic procedure, the person’s

life continues, making care and monitoring of clinical

course essential when the patient leaves the hospital and

begins a return to daily life. Moreover, as our survey

revealed a high prevalence of non-psychotic mental illness

and a strong relationship with the number of associated

diseases and the feeling of dependence in this group of

patients, we suggest a better structuring of the health sys-

tem to provide care to these chronic conditions and referral

to rehabilitation services to enable patients to regain as

much normalcy as possible and thus have a better quality of

life and psychosocial adaptation.

Conflict of interest None.

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