Determinants of depression among amputees owed to non-traumatic and traumatic causes

in Quetta
Levels of depression among patients of amputation

Abstract
BACKGROUND: An amputation is limb’s removal or its part owing to medical reasons.
Depression is a serious disabling condition and might affect independence and recovery.
Nowadays, percentage of those individuals living with a depression or anxiety, are rapidly
surging. Hence, there is a need to understand the level of depression among amputees. Objective
of study was to evaluate factors of depression among the amputees suffering non-traumatic &
traumatic causes.
Methods: Cross-sectional research was directed in Quetta city from May-July 2018. Structured
questionnaire of Hospital Anxiety and Depression Scale (HADS) was utilized to collect data
according to inclusion & exclusion criteria. This quantitative tool was respondent-centered. Chi-
square test was applied.
Results: Out of total 54 participants, 47(87%) were males and 7(13%) were females. Among
amputees, 18(33.3%) were because of non-traumatic amputation while 36(66.7 %) were caused
by traumatic injuries. Among traumatic causes, RTA (including maxilla-facial injuries) was the
main reason with 46.3 % (25) however among non-traumatic reasons, the diabetes with 24.1%
(13) was ranked first. Fall and tumor were least responsible for an amputation with just 2(4%)
contribution. 6% (3) amputations were with vascular ailments and electric shock respectively.
Mine and gunshot were responsible for 5% of the amputations respectively. Statistically-
significant relationship of amputation & marital status with depression found (p values 0.039 &
0.047)
Conclusion: Amputation has the significant association with depression level.
Sociodemographics has also association with depression. It is commended to go through a yearly
screening for depression following an amputation.
Keywords: Amputation, Depression, Injuries, Road traffic accidents, Trauma.

Introduction
Amputation is “Removal of limb or its part from a body owing to medical reasons.” It is
mandatory when limb’s disorder couldn’t be treated/cured or when there is the life-threatening
condition1. Eighty two percent of amputations happen because of peripheral-vascular disease,
any trauma, diabetes. Other causes include infection, congenital anomalies, and malignancy 2.
Sudden separation of the limb from body following limb loss or trauma caused by a severe injury
is labelled as “traumatic amputation” and most common reason of this condition is a road traffic
accidents (RTA). Traumatic limb amputations might occur due to an agricultural, occupational,
environmental, or domestic accidents, assaults and the suicidal injuries 3,4.
Depression is “A mood disorder that causes the persistent feelings of hopelessness, sadness and a
loss of interest” 5.

Nowadays, percentage of those patients having depression or anxiety, are surging swiftly, and
specifically diseased persons, victims of wars, survivors of any road traffic accidents (RTA) are
mainly affected by it. Worsened law & order circumstances and wars, has not only caused havoc
but has also surged an overall percentage of casualties amongst populace 6.
According to the World Health Organization, approximately 300 million individuals suffer from
depression & other psychiatric disorders around the globe. As a result of depression individuals
are not able to live their everyday life in a usual way. It is considered among one of commonest
health condition globally. Adults of age group 15-49 years more susceptible to become
depressing. Almost 800 thousand persons lose their lives annually, while committing suicides 7.
Disable persons can be affected by anxiety & depression easily, they are also extra-vulnerable to
contract other ailments, show risky behaviors, may even expire at a younger age. Approximately
more than one billion people are considered as disable around the earth, who face a lot of
physical functional limitations in their everyday lives. About fifteen percent persons are disable
in the world, out of which 2.54 per cent are from Pakistan, according to census of 1998 8
As per past research, about 20-60% disable persons who seek medical care for their ailments are
found as depressive and anxious1. Occurrence of the psychiatric disorders is 32-84%, one of
highest occurrence rates amongst Indian populace so far 9. Several studies 4, 6 have claimed that,
depression and anxiety are the eventual result of every single person who has lost any of her/his
body part and turn out to be disabled forever. Furthermore, due to non-availability of adequate
health facilities, there are approximately four per cent chances that these people get treatment in
an un-cordial manner by the health professionals
In order to improve their quality of life, we need to understand their problems and support them
socially, which will help them better to handle the challenges of daily living 10. Here is a dire
requirement of such sort of intercession that timely psychological and physical help can assist to
overcome their depressive complaints effectively 11.
Depression is a serious incapacitating condition and might affect independence and recovery.
Since trauma is a common cause of amputation in this region, in addition to other factors, the
severity of the depression should be understood
Suffering a traumatic injury or having surgery that results in the loss of appendage causes a
variety of emotional responses. Numerous studies have focused on the psychological effects of
removals & how to cope with such post-removal disorders. Several components observed: age,
dimension and type of removal, sexual orientation, social help, phantom limb pain, salary,
fulfillment with prosthesis. Removal rates don't seem to diminish, despite a fact that medications
are improving. Melancholy, social distress, self-perception tension and prosthetic alteration are
four probable proportions of the psycho-social change in an accordance with a removal. 12,13
Objective of study was to evaluate levels of depression among patients of amputation
METHODOLOGY
Cross-sectional research was directed in Quetta city from May-July 2018. 3 prominent
rehabilitation centers of the province were included this study. Two were NGOs based while one
was Public, based under the social-welfare department. Data was collected from clients with
amputations because of either non-traumatic or traumatic causes, visiting the 3 Physical
Rehabilitation Centers. Total 54 participants were involved through universal sampling, as this
was time bound study so all the patients who reported during the mentioned period were
included. Inclusion Criteria was “lower and upper limb uni-lateral amputees, time since an
amputation, newly amputees to ten years, amputees having non-psychiatric background and
history. Exclusion Criteria “Amputees with bi-lateral Amputation, Amputees from Afghanistan
and Amputation as a result of congenital malformation.
Structured questionnaire was used to collect data, with help of data collectors (trained) together
with a principal investigator. This respondent-centered questionnaire was assisted for question &
queries about care of these amputees. Collected data were aggregated and analyzed using the chi-
square test
RESULTS
Out of total 54 participants, 47(87%) were males and 7(13%) were females. 81.5 % subjects
were married. 26(48.1%) participants were un-educated, 20.4% and 18.5% acquired primary and
secondary education respectively, while 1.9 % completed graduation or master’s degree. When
talking about number of dependents per participant, 31.5% partakers had 9-12 no of dependents,
24% and 18.5% partakers had 2-4 and 5-8 dependents respectively. 13% subjects had dependents
13-16 or 16 & above respectively. Socio demographic characteristics of participants are
summarized in table 1.
Table 1: Socio-demographic characteristics of participants

SOCIO-DEMOGRAPHIC FREQUENCY
CATEGORY

GENDER
MALE 47
FEMALE 07

EDUCATION
Un-educated 26

Educated 28
NO OF DEPENDENTS
2-4 13

5-8 10

9-12 17

13-16 07

16 AND ABOVE 07

Among amputees, 18(33.3%) were because of non-Traumatic amputation while 36(66.7 %)

were caused by Traumatic injuries. Among traumatic causes, RTA (including maxilla-facial
injures) was the main reason with 46.3 % (25) while among nontraumatic causes, diabetes
with 24.1% (13) was ranked first. Fall and tumor were least responsible for an amputation with
just 2(4%) contribution. 6% (3) amputations were with vascular ailments and electric shock
respectively. Mine and gunshot were responsible for 5% of the amputations respectively.
Distribution of the various causes has been shown in figure 1

Chart Title
50
46
45
40
35
30
25 24

20
15
10
6 5 5 6
5 4 4

0
RTA Diabetes Fall Tumor Electric Mine Gunshot Vascular
shock ailments

Figure 1. Percentage of causes of Amputation (Traumatic or non-Traumatic)

Based on “Hospital Anxiety and Depression scale” (HADS), data of the 54 amputees showed
that 31.5% (n = 17) were normal and 68.5 %( n =37) were found to be depressed moderate to
severe disorder. 22 out of 37 were in the category of moderate depression, while 15 were
 severely depressed. Non-traumatic were more depressed as compared with Traumatic,
15(83.33%) & 22 (61.11%) respectively. Statistically-significant relationship of an amputation
with depression was found (p value=0.039). Table 2

Table 2. Level of Depression in Traumatic and non-traumatic

Cause of amputation Normal Depressive P value

Traumatic 14 22
Non-Traumatic 3 15 0.039
Total 17 37

In case of gender females are more affected as 5 out of 7 (71.42%) were depressed compared to
32 out of 47 (68%) males. Statistically significant relationship between marital status and
depression (p-value 0.047) was found. No other significant associations between depression and
other sociodemographic factors have been reported. As shown in table 3

Table 3. Levels of Depression in relation to the sociodemographic characteristics

Category Normal Depressive p-

value
Gender
Female 02 05 0.42
Male 15 32

Marital status
Married 11 33 0.047
Single 06 04

Education:

Un-educated 09 17
Educated 08 20 0.58
Discussion
Amputation is thought among one of an important public health concerns as it surges the burden
on the society and medical services 5. Research proved that a notable figure of amputees had
stood-up with mental modification problems. It is assessed that roughly 01 out of 300 individuals
in the western states experience real removal, therefore, mental alteration problems among
amputee’s might be noticed as notable medical issue 14. 16% of the entire load of ailments in the
world is due to trauma 8.
In this study, 18(33.3%) amputations were due to non-traumatic & 66.7 % were caused by the
traumatic injuries. This is nearer to those outcomes stated by Barth and colleagues, where the
traumatic amputations took place in 73.4% 15. 57.7 million Individuals were living with a limb
amputation as a result of traumatic causes globally in 2017. Falls (36.2%) was the leading
traumatic cause for limb amputation, followed by road-traffic injuries (15.7%), while other
transportation injuries & mechanical forces accounts for 11.2% and 10.4% respectively 16
RTA is the main reason for facial trauma. Along with skeletal fractures, traumas of facial region
may also include serious damage to soft tissue or an amputation with consequent functional &
aesthetic issues. Prominent anatomic parts/structures, such as nose, ears and lips, are generally
involved. Along with their aesthetic significance, lips are essential for swallowing & talking
purpose. Afterwards traumatic amputation, reconstruction of those facial parts is of special
interest because of psychological and functional implications these accidents have had on
patients 17

Among traumatic causes in our study, RTA (including maxilla-facial injuries) was the main
reason with 46.3 % (25) while among nontraumatic causes, diabetes 24.1% (13) was ranked first.
Fall and tumor were least responsible for an amputation with just 2(4%) contribution. 6% (3)
amputations were with vascular ailments and electric shock respectively. Mine and gunshot were
responsible for 5% of the amputations respectively.
In a research of Perales S and his colleagues’ diabetic percentage was 55%, which is
considerably greater than this study 18 whereas, diabetic percentage in our investigation is almost
alike that listed by Padovani and his team (20%) 19. In this research, vascular diseases resulted in
six per cent amputations. This is different from those findings told by Yilmaz, where causes for
an amputation were vascular illness in 57 % (77) patients 20. The figure for the gunshot in our
study is lesser than that stated by Khoshmohabat (23.9%) 21.

Post-traumatic amputees are more susceptible to get depression, and they may suffer from “PTSD
(post-traumatic stress disorder)” or any other similar psychological condition because of memories of that
traumatic event. Symptoms could include nightmares; insomnia; flashbacks; depression; avoidance; anger
outbursts, along with numerous other challenging behaviors. Most probably a patient hurting from any traumatic
amputation will feel psychological & an emotional impact more severely than that person who underwent a
planned surgical-amputation, because they do not have time to prepare for limb injuries.
Furthermore, several psycho-social, socio-economic, & physical conditions could occur in those
individuals getting amputation because of accidents or trauma 22, 23. Similar outcomes were
conveyed by a researcher who endorsed that the psycho-social complaints were the end result of
the amputations, patients showed greater/higher anxiety & depressive conditions with the
amputations. Thus, there overall rehabilitation process and health seeking behavior become
disrupted as a result of psychiatric problems/issues, therefore, before the beginning of their
rehabilitation, it is actually imperative to diagnose and detect amputees for an existence of
depressive conditions 24.
Predictors/forecaster for the poor quality of life (QOL), includes post-traumatic stress,
Depression & anxiety 8. Sahu and Anamika, in an Indian research, backed a fact that,
posttraumatic maladies can advance in those patients who acquired an amputation as a result of
any trauma or accident and different psychological effects could occur in these affected
individuals as well. They turn into less confident individuals socially, as feelings of losing of
their body part make them uncomfortable with an appearance, hence, un-able to face this new
reality of their life 7, 25.
Non-traumatic were more depressed as compared with Traumatic, 15(83.33%) & 22 (61.11%)
respectively, which is comparable with outcomes stated by Hawamdeh & colleagues where 37%
individuals were affected 26.
In this study, statistically significant relationship between marital status and depression (p-value
0.047) was found. Similarly, Iqbal M in his research (p value <0.01) told a significant relation
with being a single i.e marital status 27. This is like that listed by Faraj, where investigators
expected that few sociodemographic factors could have relation with the psychiatric co-
morbidity 28.

Limitations

The sample size small as it was time bound study. Period since amputation wasn’t considered. It
was tough to get confidence of most partakers owing to particular time for rehabilitation at a
rehabilitation Centre. Difficulty in data collection due to social problems/issues as most ladies
avoid to talk or express their feelings owing to cultural values in that region.

Conclusion
Amputation and depression had a significant association. High prevalence of depression amongst
amputees showed that clinicians should pay attention for timely detection of depression symptoms and
amputated patients must be psychiatric counseled & treated This research gives an insight for the
Multi-disciplinary team members in general and physiotherapist professionals in particular that
depression do exist at some time surrounding an amputation & several factors can considerably
influence level of depression among the amputees particularly as a result of traumatic causes. It
is commended go through a regular or yearly screening of depression following an amputation.

References
1. Şimsek N, Küçük Öztürk G, Nahya ZN. The Mental Health of Individuals with Post-
Traumatic Lower Limb Amputation: A Qualitative Study. Journal of Patient Experience.
2020, Vol. 7(6) 1665-1670
2. Terry Canale S, Beaty JH. Campbell’s Operative Orthopaedics. Bas¸bozkurt M, Yıldız C,
c¸eviri edito¨ rleri. Gu¨nes¸ Tıp Kitapevleri, 11. 2011:561-639.
3. Aslan MD, Çulha C, YANIKOĞLU İ, Malas FÜ, Güntepe Ş, Özgirgin N. Clinical and demographic
characteristics of patients with lower limb amputation. Ege Tıp Dergisi. 2019 Mar 14;58(1):46-51.
4. Asirdizer M, Hekimoğlu Y, Keskin S. Investigation of effective factors on traumatic amputations
due to road traffic accidents. Injury. 2022 Mar 1;53(3):966-71.
https://doi.org/10.1016/j.injury.2021.11.021
5. Chand SP, Arif H. Depression. [Updated 2022 Jul 18]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK430847/
6. Ghous M, Gul S, Siddiqi FA, Pervaiz S, Bano S. Depression ; Prevalence Among
Depression ; Prof Med J. 2015;22(2):263–6.
7. WHO | Depression. WHO [Internet]. 2017; Available from:
http://www.who.int/mediacentre/factsheets/fs369/en/ (accessed on May 2021)
8. WHO | Disability and health. WHO [Internet]. 2018; Available from:
http://www.who.int/mediacentre/factsheets/fs352/en/ (accessed on May 2021)
9. Sahu A, Sagar R, Sarkar S, Sagar S. Psychological effects of amputation: A review of
studies from India. Industrial psychiatry journal. 2016 Jan; 25(1):4-10.
10. Bhutani S, Bhutani J, Chhabra A, Uppal R. Living with amputation: anxiety and
depression correlates. Journal of clinical and diagnostic research: JCDR. 2016
Sep;10(9):09-12
11. Pedras S, Carvalho R, Pereira MG. A predictive model of anxiety and depression
symptoms after a lower limb amputation. Disabil Health J [Internet]. 2016;11(1):79–85.
Available from: https://doi.org/10.1016/j.dhjo.2017.03.013
12. Desteli EE, İmren Y, Erdoğan M, Sarısoy G, Coşgun S. Comparison of upper limb
amputees and lower limb amputees: a psychosocial perspective. Eur J Trauma Emerg
Surg. 2014;40(6):735–9.
13. Copanitsanou P, Drakoutos E, Kechagias V. Posttraumatic stress, depressive emotions,
and satisfaction with life after a road traffic accident. Otrhop. Nurs. 2018; 37:43–53.
doi: 10.1097/NOR.0000000000000417.
14. Donovan-Hall MK, Yardley L, Watts RJ. Engagement in activities revealing the body
and psychosocial adjustment in adults with a trans-tibial prosthesis. Prosthet Orthot Int.
2002;26(1):15–22.
15. Barth CA, Wladis A, Blake C, Bhandarkar P, Perone SA, O'Sullivan C. Retrospective
observational study of characteristics of persons with amputations accessing International
Committee of the Red Cross (ICRC) rehabilitation centres in five conflict and
postconflict countries. BMJ open. 2021 Dec 1; 11(12):1-16.
16. McDonald CL, Westcott-McCoy S, Weaver MR, Haagsma J, Kartin D. Global
prevalence of traumatic non-fatal limb amputation. Prosthetics and orthotics
international. 2020 Dec 4:0309364620972258.
17. AlQahtani FA, Bishawi K, Jaber M. Analysis of the pattern of maxillofacial injuries in
Saudi Arabia: a systematic review. The Saudi dental journal. 2020 Feb 1;32(2):61-7.

18. Perales MS, Cortés MG, Utiel FB, Viedma G, Gil J, del Barrio PP, Hinojosa JB, Liébana
A, Bañasco VP. Incidence and risk factors for non-traumatic amputation of lower limbs
in patients on hemodialysis. Nefrologia. 2005; 25:399-406.
19. Padovani MT, Martins MRI, Venâncio A, Forni JEN. Anxiety, depression and quality of
life in individuals with phantom limb pain. Acta Ortop Bras. [online]. 2015; 23(2):107-
10. Available from URL: http://www.scielo.br/aob.
20. Yilmaz M, Gulabi D, Kaya I, Bayram E, Cecen GS. The effect of amputation level and
age on outcome: an analysis of 135 amputees. European Journal of Orthopaedic Surgery
& Traumatology. 2016 Jan 1; 26(1):107-12.
21. Khoshmohabat H, Rasouli HR, Forozanmehr MJ, Kalantar Motamedi MH, Saghafinia M.
The prevalence of trauma injuries from neighboring countries transferred to Iran. Int J
Travel Med Glob Health. 2017; 5(4):140-143. doi:10.15171/ijtmgh.2017.27.
22. https://www.seriousinjurylaw.co.uk/other-serious-claims/amputation/effects-of-
amputation/ (accessed on May 2021)
23. Mckechnie PS, John A. Anxiety and depression following traumatic limb amputation: A
systematic review. Injury [Internet]. 2014 Dec [cited 2018 Feb 20];45(12):1859–66.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/25294119
24. Machado Vaz I, Roque V, Pimentel S, Rocha A, Duro H. Caracterização psicossocial de
uma população Portuguesa de amputados do membro inferior. Acta Med Port.
2012;25(2):77–82.
25. Baqi A, Zia Q, Shaikh SP, Shoaib M, Javaid MM, Malik MS. Determinants of anxiety in
amputees owed to traumatic & non-traumatic causes. Ann Pak Inst Med Sci. 2022;18
(3):175-80
26. Hawamdeh ZM, Othman YS, Ibrahim AI. Assessment of anxiety and depression after
lower limb amputation in Jordanian patients. Neuropsychiatric disease and treatment.
2008 Jun;4(3):627-33
27. Iqbal MM, Mohamed S, Mohamad M Depression and Its Associated Factors among
Lower Limb Amputees at Hospital Kuala Lumpur and Hospital Sultanah Bahiyah: A
Cross Sectional Study. J Depress Anxiety 2019 8 (2): 338.
28. Faraj IM, Mutavi TN, Gitau CW. Prevalence of Anxiety, Depression, and Post-Traumatic
Stress Disorder Among Amputees Attending Jaipur Foot Trust Artificial Limb Centre in
Kenya. East African Journal of Health and Science. 2022 Mar 8;5(1):49-64.