In a prospective screening study of 50 people with diabetes and active foot ulceration, mild-to-moderate levels of depression and anxiety were highly prevalent and highly correlated with each other, with depression scores associated with higher HbA1c, greater number of prescribed medications, and insulin treatment.
Key Findings
Results
Depression and anxiety symptoms were prevalent at mild-to-moderate levels in people with diabetes attending a podiatry clinic with active foot ulceration.
Median (IQR) PHQ-9 score for depression was 9 (3–16), indicating mild-to-moderate depression
Median (IQR) GAD-7 score for anxiety was 4 (0.5–9.0), indicating mild-to-moderate anxiety
Sample consisted of 50 patients, 86.7% male, mean age 65.4 (SD 12.9) years
Eight patients had type 1 diabetes and 42 had type 2 diabetes
Median time since diabetes diagnosis was 14.5 (3.1) years
Results
Depression and anxiety scores were highly positively correlated with each other.
Spearman's rho between PHQ-9 and GAD-7 was 0.791 (p < 0.001)
Both scores also correlated positively with the diabetes distress scale score
PHQ-9 correlated with total of the 2 diabetes distress score items (rho 0.456, p = 0.006)
Spearman's rho was used due to skewed distributions of variables
Results
Both depression and anxiety symptoms declined significantly with increasing age.
Age was significantly and inversely correlated with anxiety (rho -0.472, p = 0.017)
Age was significantly and inversely correlated with depression (rho -0.250, p = 0.040)
This inverse relationship held for both PHQ-9 and GAD-7 scores
Results
Higher depression scores were associated with a higher number of prescribed medications.
PHQ-9 correlated positively with number of individual pharmacological agents (rho 0.490, p = 0.001)
Median (IQR) number of separate drugs in the sample was 10.5 (4.1)
Median (IQR) number of comorbidities was 8.3 (3.9)
Results
Higher depression scores were associated with higher current HbA1c levels.
PHQ-9 score correlated positively with HbA1c (rho 0.421, p = 0.007)
42% of patients had CKD (estimated GFR < 60 mL/min/1.73 m²)
This association suggests poorer glycaemic control relates to greater depressive symptomatology in this population
Results
Insulin treatment was associated with higher PHQ-9 depression scores.
People receiving insulin treatment had higher PHQ-9 scores compared to those not on insulin
This association was identified through analysis of medical history obtained from primary and secondary care electronic health records
The direction and magnitude of the specific comparison were noted as a study finding
Results
Ulcer healed status at 12 weeks was not associated with any questionnaire score.
Neither PHQ-9 nor GAD-7 scores were associated with foot ulcer healing status at 12 weeks
Diabetes distress scale scores were also not associated with 12-week healing outcomes
All 50 patients had active foot ulceration at time of assessment
Results
The study population had a high burden of comorbidities and polypharmacy.
Median (IQR) number of comorbidities was 8.3 (3.9)
Median (IQR) number of separate drugs was 10.5 (4.1)
42% of the patients had CKD with estimated GFR < 60 mL/min/1.73 m²
86.7% of patients were men, reflecting the demographic of this high-risk foot clinic population
What This Means
This research suggests that people with diabetes who have foot ulcers carry a significant burden of depression and anxiety, often unrecognised until formally assessed. In a group of 50 patients attending a specialist foot clinic, researchers used standardised questionnaires (PHQ-9 for depression and GAD-7 for anxiety) and found that on average, participants scored in the mild-to-moderate range for both conditions. Importantly, many of these cases may not have been previously identified, highlighting the value of routine screening in this clinical setting.
The study found that depression and anxiety were strongly linked to each other, and both were also connected to diabetes-related distress. People with higher levels of depression tended to have poorer blood sugar control (higher HbA1c), were taking more medications, and were more likely to be on insulin therapy. Younger patients tended to experience higher levels of both depression and anxiety compared to older patients, which was an unexpected finding. Notably, whether or not a patient's foot ulcer had healed after 12 weeks was not related to their depression or anxiety scores.
This research suggests that people living with diabetes and foot ulcers face a complex and interconnected set of challenges — physical, psychological, and pharmacological — that all occur simultaneously. Routine screening for depression and anxiety in podiatry and diabetes foot clinics could help identify individuals who might benefit from additional mental health support alongside their physical care, particularly younger patients and those with less well-controlled diabetes or more complex medication regimens.
Fletcher E, Allen M, Sharpe A, Ibad M, Mordaunt M, Callen R, et al.. (2026). Screening for Depression and Anxiety in People With Diabetes and a Foot Ulcer in the Podiatry Clinic.. Journal of foot and ankle research. https://doi.org/10.1002/jfa2.70208