Shattered Spirits: Unveiling the Emotional Abyss - Exploring the Profound Impact of Amputation Levels on Mental Well-being

Amputation is an undesirable outcome of peripheral arterial disease (PAD) that affects both the mobility and broader lifestyle of the patient. Prior studies have shown that lower extremity amputation is associated with increased rates of postoperative diagnosis of depression. However, these studies are primarily single-center and do not include analysis over various timepoints. The objective of this study was to ascertain an extent and time- dependent association between lower extremity amputation and postoperative development of depression. This information will allow vascular surgeons to make the necessary psychiatric referrals prior to development of depressive symptoms. A total of 46,034 adult patients who underwent PAD-related lower extremity amputation were identified from TriNetX Research database following exclusion of those with preoperative depression or use of antidepressants. Propensity score matching was used to develop a major amputation cohort (above-knee amputations, below-knee amputations) (I) and minor amputation cohort (Toe and foot amputations) (II), each with 14,511 patients. Primary outcomes included postoperative diagnosis of depressive episode, major depressive disorder (MDD), and prescription of antidepressants. Outcomes were analyzed at 6 months and 5 years via Kaplan-Meier analysis, and results were reported as hazard ratios (HRs), 95% confidence intervals (CIs), and significance set to P < .05. Analysis at 6 months demonstrated that major amputation was associated with a higher risk of developing depressive episodes (7.5% vs 5.2%; HR, 1.537; 95% CI, 1.400-1.687; P-value < .001), MDD (0.6% vs 0.4%; HR, 1.664; 95% CI, 1.179-2.356; P-value < .001), and requiring antidepressants (17.6% vs 6.8%; HR, 2.903; 95% CI, 2.698-3.124; P- value < .001) when compared with minor amputation. Analysis at 5 years demonstrated that both major and minor amputees experienced greater risk of all three outcomes including depressive episodes (12.6% vs 11.8%; HR, 1.223; 95% CI, 1.145-1.307; P-value < .001), MDD (1.5% vs 1.3%; HR, 1.267; 95% CI, 1.042-1.540; P-value < .001), and antidepressant prescriptions (24.9% vs 16.4%; HR, 1.859; 95% CI, 1.765-1.958; P-value < .001). Major amputees continued to experience higher risk of all three primary outcomes compared with their minor amputee counterparts. Patients who underwent major amputations were more likely to experience postoperative depressive episodes, MDD, and require antidepressants than patients who underwent minor amputation. These patients were also more likely to experience these mental health-related outcomes in a shorter time frame than those with minor amputations. This suggests that vascular surgeons should consider referral of major amputees to psychiatric experts prior to 6 months postoperatively.