Diabetic foot disease is usually described in physical terms: sensory loss, perfusion, wound depth, bacterial burden. Yet the person carrying the ulcer is also carrying months of dressing changes, restricted walking, lost work, and the knowledge that amputation is a possible endpoint. Research published over the past decade has examined how depression and psychological distress intersect with diabetic foot ulceration: how common they are, whether they predict ulceration or poor healing, and what happens to mood after amputation. This matters clinically because psychological state influences the behaviours foot care depends on — offloading adherence, daily foot inspection, and clinic attendance.
How common is depression in diabetic foot ulceration?
Depression is far more prevalent in this population than in diabetes generally. A systematic review and meta-analysis by Jiang and colleagues pooled 11 studies involving 2,117 patients with diabetic foot ulcers and estimated the overall incidence of depression at 47% (95% CI 36–58%), with individual study estimates ranging from 26% to 85%. Heterogeneity was high and driven largely by differences in the screening instruments used rather than by patient age or diabetes duration.
A more recent meta-analysis by Ying and colleagues, covering 19 studies, arrived at a closely comparable figure of 45%. That analysis also identified age, ulcer duration, and Wagner ulcer classification as factors significantly associated with depressive symptoms — suggesting that the longer and deeper the wound, the greater the psychological toll.
Distress in this group is not limited to depression. A cohort study by Nguyen and colleagues at a hospital diabetic foot unit found elevated rates of depression, anxiety, post-traumatic stress symptoms, and diabetes distress, together with negative illness perceptions and differences in emotion regulation. Prior mental health history, higher HbA1c, and the presence of other diabetes complications were each associated with greater psychological symptom burden.
Cognition is also affected
The same research group assessed 80 adults with diabetes-related foot complications using a comprehensive neuropsychological battery and found performance significantly below age-matched norms on most tasks, with the largest decrements in inhibitory control, verbal memory, verbal abstract reasoning, and working memory. Lower education, higher HbA1c, longer diabetes duration, and vascular disease were associated with poorer performance. Because foot care depends on planning, recall, and consistent daily routines, executive and memory impairment is a plausible barrier to self-management that is easily mistaken for non-adherence.
Does psychological state predict ulceration or healing?
Here the evidence is more nuanced. A systematic review by Westby and colleagues examined 15 longitudinal studies with multivariable analyses, involving more than 12,000 participants, and found that the answer depends on ulcer history. Among people with diabetes and no prior ulcer, moderate-quality evidence indicated that depression increased the risk of a first ulcer (for example, a hazard ratio of 1.68 per standard unit on the Hospital Anxiety and Depression Scale), while better foot self-care behaviour reduced it (HR 0.61 per standard unit). Among people with a previous ulcer, however, the association between depression and recurrence largely disappeared, and evidence regarding footwear adherence and exercise was low or very low quality. One study found incomplete clinic attendance strongly associated with amputation (OR 3.84).
Whether depression slows healing remains unsettled. A 2025 systematic review by Al-Smadi and colleagues identified 11 studies with 1,392 participants: five reported a significant negative association between depression and healing outcomes, while six found none. Study quality was mixed, and the authors concluded that the question requires higher-quality prospective work before firm claims can be made.
The impact of hospitalisation and amputation
Acute deterioration carries a measurable psychological cost. Using the PROMIS instrument, Johnson and colleagues compared patients hospitalised with diabetic foot infection against propensity-matched outpatients attending for routine foot care. Hospitalised patients scored significantly worse on six of seven domains — physical function, anxiety, depression, fatigue, social role, and pain intensity — with only sleep disturbance showing no difference.
Minor amputation appears to be a distinct psychological event rather than a minor procedural step. In a multimethod study by Brooks and colleagues examining patients undergoing single-toe or partial ray resection, mean PHQ-9 scores rose from 3.65 before surgery to 12.35 afterwards, with 18 of 20 patients scoring higher post-operatively. The same research group has described a “diabetic foot–pain–depression cycle,” reporting that patients using antidepressant medication had markedly lower odds of continuing opioid use beyond seven days after forefoot amputation.
Longer-term adjustment data reinforce the point. In a longitudinal study of patients undergoing lower limb amputation for type 2 diabetes, Pedras and colleagues found that pre-surgical anxiety and early post-operative traumatic stress symptoms predicted poorer psychosocial adjustment at 10 months, with perceived social support mediating that relationship. In a population cohort of 1,053 patients undergoing a first lower-extremity amputation, antidepressant drug use was among the independent predictors of death after major amputation, alongside age and chronic renal disease.
Clinical summary
Roughly 45–47% of patients with diabetic foot ulcers screen positive for depression, and distress extends to anxiety, post-traumatic symptoms, and measurable cognitive impairment. Depression appears to raise the risk of a first ulcer, though its relationship with recurrence and with healing rate is less certain. Hospitalisation for infection and even minor amputation are associated with sharp deterioration in mood and quality of life, and psychological variables track with longer-term adjustment and mortality. Taken together, the literature supports routine screening for depression in diabetic foot disease, attention to cognitive barriers when self-management appears inconsistent, and the inclusion of mental health expertise within multidisciplinary limb preservation teams.
References
- Jiang F-H, Liu X-M, Yu H-R, Qian Y, Chen H-L. The Incidence of Depression in Patients With Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis. The International Journal of Lower Extremity Wounds. 2022;21(2):161–173.
- Ying Y, Lv Y, Zhu H, Zhang Y, Fang X. The incidence of depression and its associated risk factors among diabetic foot ulcers patients: A meta-analysis and systematic review. Journal of Tissue Viability. 2025;34(4):100964.
- Westby M, Norman G, Vedhara K, Game F, Cullum N. Psychosocial and behavioural prognostic factors for diabetic foot ulcer development and healing: a systematic review. Diabetic Medicine. 2020;37(8):1244–1255.
- Al-Smadi AM, Finlayson K, Andrew B, Parker C. The impact of depression on healing outcomes in people with diabetes-related foot ulcers: A systematic review. Diabetes Research and Clinical Practice. 2025;225:112275.
- Nguyen ML, Wong D, Barson E, Staunton E, Fisher CA. Psychological factors in diabetes-related foot complications: A cohort study. Journal of Health Psychology. 2025;30(10):2577–2597.
- Nguyen ML, Wong D, Barson E, Staunton E, Fisher CA. Cognitive dysfunction in diabetes-related foot complications: A cohort study. Journal of Diabetes and Metabolic Disorders. 2024;23(1):1017–1038.
- Johnson MJ, Wukich DK, Nakonezny PA, et al. The Impact of Hospitalization for Diabetic Foot Infection on Health-Related Quality of Life: Utilizing PROMIS. The Journal of Foot and Ankle Surgery. 2022;61(2):227–232.
- Brooks LM, Brooks BM, Arp AS, et al. Diabetes-Related Extremity Amputation Depression and Distress (DREADD): A Multimethod Study. Seminars in Vascular Surgery. 2025;38(1):94–100.
- Brooks BM, Shih C-D, Brooks BM, et al. The Diabetic Foot-Pain-Depression Cycle. Journal of the American Podiatric Medical Association. 2023;113(3).
- Pedras S, Vilhena E, Carvalho R, Pereira MG. Psychosocial adjustment to a lower limb amputation ten months after surgery. Rehabilitation Psychology. 2018;63(3):418–430.
- Cascini S, Agabiti N, Davoli M, et al. Survival and factors predicting mortality after major and minor lower-extremity amputations among patients with diabetes: a population-based study using health information systems. BMJ Open Diabetes Research & Care. 2020;8(1):e001355.
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