Evaluation of depressive symptoms in patients with venous ulcers

Background: Venous ulcers play an important role in patients’ lives, as the incidence of deformities caused by this type of wound might produce adverse consequences, including psychosocial disorders. The objective of this study is to evaluate the occurrence of depres sive symptoms presented by patients with venous ulcers. Methods: An exploratory, descriptive, analytical, and cross-sectional study was conducted at the Outpatient Wound Clinic of the Hospital Set within the State of São Paulo. The data were collected by interviews between December 2008 and April 2009 after approval of the research project by the Research Ethics Committee of the Federal University of São Paulo (CEP-1611/08). The Beck Depression Inventory was the instrument of the study. Results: Sixty patients participated in the survey. The majority (91.66%) showed some level of depression. There was a higher frequency of symptoms ranging from mild to moderate (n = 39; 65%). All le­vels­of­depression­showed­statistical­differences.­The­five­symptoms­most­commonly­ found were sadness, distorted body image, self-depreciation, decreased libido, and social withdrawal. Symptoms less represented were suicidal ideation and loss of appetite, each men tioned by only one patient. Forty-three patients were over 61 years old. Of these, 38 (88.4%) had depressive symptoms ranging from mild to severe. Conclusions: The data obtained and evaluated by the Beck Depression Inventory allow the conclusion that patients with venous ulcers present different levels of depressive symptoms.


INTRODUCTION
The presence of chronic ulcers in the lower limbs affects up to 5% of the adult population in the western countries, causing a significant socioeconomic impact.Its etiology is associated with several factors, such as chronic venous disease, peripheral arterial disease, neuropathies, arterial hypertension, physical trauma, sickle cell anemia, skin infections,inflammatorydiseases,neoplasias,andnutritional changes 1 .
Studies show a prevalence of venous ulcers around 0.3% 1,2 .Their incidence increases with age, exceeding 4% in people over 65 years old and 1% of the adult population with a history of active or scarred ulcers; therefore, they are considered a serious problem for public health 1,2 .
Venous ulcers are a chronic disease that is characterized by periods of exacerbation and remission.Their long healing process generates physical and psychological discomfort.Restrictions resulting from the resulting treatment alter the individual's way of life and interfere with the daily activities of the individual [3][4][5] .
The population most affected by venous ulcers is the el derly, who have, in addition to the wound, a decline in their activities because of their chronic degenerative diseases.Emotional support and mechanisms to face this situation are therefore required, since these people often have shaken emotions and feelings.
Having a wound, with its associated exudate, odor, pain, anddifficultyhealing,limitedtheindividual'spossibilities to transform his/her existence.Family, social, and leisure relationships are important for the recovery of these injured people, and the lack of these activities might lead to a reduction in their quality of life, lowered self-esteem, anxiety, and depression 5 .
A study on the prevalence of anxiety and depression in 190 patients with chronic venous ulcers performed using the Hospital Anxiety and Depression Scale (HADS) revealed that 52 (27%) patients with depression and 50 (26%) were classified as anxious.The two symptoms associated with anxiety and depression were pain and odor 3 .
Pain and quality of life ratings among 233 females and 148 males were evaluated in a study of patients with chronic ulcers using the SF-12 survey and the visual analogue scale (VAS).Women reported more pain and worse quality of life than men.A direct correlation between pain and quality of life was detected.The authors concluded that vascular ulcers are very painful and result in poor quality of life, with a decline in self-esteem and depression 6 .
Depression is considered one of the ten leading causes of disability worldwide, limiting performance in physical, social, and personal activities.However, only a small number of affected people receive an appropriate treatment.
Thewaythepopulationidentifiessymptomsofdepression (and their beliefs about the etiology of depression) might influencetheprocessesofseekinghelpandtreatmentconsent and the community's attitude and behavior toward people with this disorder 7 .
However, depression has been underdiagnosed, undertreated, and undetected by the doctor in around 50-60% of the cases.In addition, depressed patients very often receive an inadequate and non-specific treatment.The morbidity associated with depression might be largely (around 70%) pre vented with the correct treatment 8 .
Venous leg ulcers play an important role in the patient's life, as the incidence of deformities caused by this type of wound might induce adverse consequences, including psychosocial disorders.
Investigation and treatment of depression, especially in the practice of health professionals treating people with skin wounds,isnotalwaysemphasizedasabenefittoincreasethe patient's quality of life, self-esteem, or self-image.In keeping with this notion, the present study is aimed to evaluate the incidence of depressive symptoms reported by patients with venous ulcers.

METHODS
An exploratory, descriptive, analytical, cross-sectional study was conducted at the Outpatient Wound Clinic of the Hospital Set in the State of São Paulo.
The criteria for inclusion in the study were as follows: diagnosis of venous ulcers by a vascular surgeon, age over 18 years old, and treatment at the outpatient wound clinic.
Salomé GM et al.
We excluded patients who, according to the evaluation of the investigator, presented physical or mental conditions that prevented them from answering the questions of the survey.
The data were collected by interviews between December 2008 and April 2009 after approval of the research project by the Research Ethics Committee of the Federal University of São Paulo (CEP-1611/08).
The data were collected by researchers after obtaining, in writing, the free informed consent of each patient in a previously prepared room, guaranteeing comfort and tranquility to the interviewee.
The study used the Beck Depression Inventory 8,9 as an instrument to measure and self-evaluate depression.It is employed in the clinic, in research, and is considered to be a complement to patient evaluation 10 .
The inventory presents 21 categories of symptoms and attitudes typical of depression and each one is rated in terms of four different degrees of intensity of manifestation (0-3 points), totaling 63 points.
The validation and reliability verification of the Beck De pressionInventorywerecarriedoutinthreesamples:first, theprofileofscoresobtainedinasampleofBrazilianundergraduate students was assessed with the Beck Depres sion Inventoryandcomparedtoprofilesobtainedwithdiffe rent versions in terms of languages and cultures.The internal consistency of the Beck Depression Inventory was high (0.81),andthegeneralpatternofresultsconfirmedthevalidity of the Portuguese version of the survey.In the second study, the Portuguese version of the Beck Depression Inventorywasassessedbyobtainingitsprofileinthreesamples: undergraduate students, patients with panic, and patients with depression.In the third study, other psychometric properties, such as gender differences in depressive symptoms, were investigated by factorial and discriminant analysis in a large non-clinical sample of undergraduate students.Regarding reliability, the internal consistency of the scale was 0.81 for the full sample, 0.76 for the subsample of males, and 0.83 for females.In the validation study, the internal consistency of the sample for depressed patients was 0.88.
Data analysis was performed employing the SPSS software package version 15.0; chi-squared tests of independence and Kruskal-Wallis tests were used.

RESULTS
Sixty patients participated in the survey and the majority (91.66%) presented some level of depression (Table 1).There was a higher incidence of symptoms in the range from mild to moderate (n = 39, 65%).All levels showed statistical differences.
AsshowninTable2,thefivemostcommonsymptoms were sadness, body image distortion, self-depreciation, decreased libido, and social withdrawal.The less-represented symptoms were suicidal ideation and loss of appetite, each one described by a patient.
In terms of age, 43 patients were over 61 years old, among whom 38 (88.4%) presented depressive symptoms ranging from mild to severe.Of 51 (85.01%) white patients, 22 (36.69%)presented depression ranging from mild to mo derate.Regarding marital status, there was a predominance of divorced patients.However, depressive symptoms also appeared in single, married, and separated people.There were statistically significant differences in rates of depression in terms of age group and marital status (P = 0.001) (Table 3).
In the sample studied, the majority of the patients were female individuals, who presented an intensity of depressive symptoms that ranged from mild to severe (Table 4).

DISCUSSION
People with wounds might isolate themselves; this occurs when the patient is moved by fear to suffer as a result of skin injury, pain, odor, and exudate.
Consequently, because of the difficulties of facing this inconvenience, patients suffering from injuries avoid social contact, become more isolated, and thus develop anxiety, de pression, and mental disorders that affect their physical and psychological functioning 5 .
Depressive disorder is very prejudiced in terms of perso nal and familiar life, affecting twice as many women as men 10 .In 1990, depression was estimated to be the fourthmost-common specific cause of disability when a global sca le of comparison between various diseases was used.The estimate for 2020 is that it will be the second-leading cause in developedcountriesandfirst-placeindevelopingcountries 10 .
In this study, 39 patients presented mild to moderate depression; this constitutes an incidence rate that is higher than the one shown by Duarte & Rego 11 , who found that 10-20% of patients with clinical diseases present depressive symptoms and about 5% have serious complications.
Using a version of the Beck survey validated by Gorestein and Andrade 12 in patients with chronic indiscriminate wounds, it was found that the majority of individuals presented depression ranging from mild to moderate.
Other researchers have reported that when a patient gets an ulcer, several changes occur in his/her lifestyle regarding leisure, pain, social restriction, school, locomotion, and alteration in physical appearance that might lead the patient to  experience depression [13][14][15] .Several studies of venous ulcer patients reveal that over 50% presented depression, results thatconfirmthefindingsofthisstudy [13][14][15] .Depressive symptoms manifested by negative body im a ge, sadness, self-depreciation, and decreased libido shown in this study were similar to those identified in a previous work that investigated the relationship between depression and chronic comorbidities, although using different evaluation methods 3,16 .
In this research, the majority of the patients were elderly (71.67%) females (58.35%) who presented intensities of depressive symptoms that ranged from mild to severe.
Currently, it is known that depression is 50-75% more diagnosed in women than in men; however, the causes of this difference are unknown.Hormonal factors, genetic predisposition linked to the X chromosome, and even cultural factors are associated with causes of depression, which is more detectable in females given their higher tendency to express emotions and search for treatment 14 .However, this studyfoundnosignificantdifferencesindepressionrateson the basis of gender or depressive symptoms.
Studies have shown that ulceration affects work productivity and functional capacity, sometimes leading to disability retirement or restriction of the activities of daily life and lei sure.
For many patients, chronic diseases associated with wounds cause pain, loss of mobility/functional capacity, and decreased quality of life, resulting in anxiety and depression 5,13,15,17 .
Several authors have found a correlation between functional disability and health factors, among other correlations.Health self-perception seems to be the factor most strongly related to functional disability in Brazilian elderly people, followed by chronic diseases 15 .
In this context, it is worth emphasizing that humor-related depressive disorders are more frequent in elderly, being the fourth-leading cause of disability in the social world.
The growth of the elderly population is a factor of increasing importance, as it already exceeds the growth rate of the total population.
In a study in which depression was assessed in patients with leg ulcers, the authors found that women aged above 60 years presented alterations in the level of depression 3,14,16,18 .Depression appeared elevated in all of the age groups, which demonstrated that the environment and their expectations of the procedures might be considered stressful factors by this population.Health care in this age group has become a global concern.
Therewerenostatisticallysignificantdifferencesinthe presence of ulcers and age among patients with depressive symptoms.The elderly with wounds are precisely in whom this disorder occurs.
The elevated rate of wounds in this population is a circums tance that is known by health professionals and has ge nerated several discussions.Health care of people with woundsisasignificantproblemthatrepresentsachallenge to be faced daily by patients and their caregivers.Having an ulcer provokes a series of changes in peoples' lives and, consequently, in their relatives' lives, creating diffi cultiesforwhichtheyareoftennotprepared 3,14,15 .
Ulceration in the lower limbs of the elderly is a condition that leads the patient to social isolation as a result of worsening mobility, reduced functional ability, and pain, causing decreased quality of life, low self-esteem, compromised selfima ge, and depression 3,19 .
Depression in the elderly is an important problem in public health given its high prevalence, frequent association with chronic diseases, negative impact on quality of life, and risk of suicide.
The increased frequency of depressive symptoms among the widowed, divorced, and separated (compared to that among the single and married) suggests a correlation between living without a partner and high incidence of depression.In addition, people who live alone appear to be more vulnerable.
It was found in this sample that most of the patients with depressive symptoms were separated or single women (68.98 %), whereas among married people, the incidence rate of depression was 21.98%, a difference that presented statistical difference (P = 0.001).
People with wounds need to be helped to understand that the lesion is not a restriction against a social and sexual life but needs to be seen as a new condition that requires adap tation.
Becauseitisdifficulttocoexistwithasituationthatinvolves changes, it becomes necessary to seek the help of a professional to make the patient feel supported and motivated to seek further help.
The results of this study indicate the need to redirect assis tance to patients with wounds.A search for and identi ficationofemotionaldisordersamongthesepatients is recommended in health services, hospitals, outpatient clinics, and home care.
Considering the needs arising in past decades, the increa se in chronic diseases and the number of people with wounds makesitnecessarytoredirectacademictrainingandqualification of health professionals, valuing not only content but also care practice.
This initial contribution to a theme suggests that future studies need to be performed that increase the sample size in ordertodescribetheinfluenceofothervariablesandunderstand the magnitudes and consequences of possible changes in the emotional sphere for patients with venous ulcers.
Actions to address chronic diseases and mental health will certainly contribute to the welfare and quality of life of people who live with chronic ulcers, especially the elderly.

CONCLUSIONS
The results obtained when we administered the Beck Depression Inventory allow us to conclude that patients with venous ulcers present various levels of depressive symp toms.

Table 1 -
Classificationofdepressionlevelsin patients with venous ulcers according to theBeck Depression Inventory.

Table 2 -
Symptoms of depression presented by patients with venous ulcers.

Table 3 -
Distribution of levels of depression (as per the Beck Depression Inventory) among patients with venous ulcers according to age and marital status.

Table 4 -
Classificationofdepressionlevelsin patients with venous ulcer, according to the Beck Depression