==== Front JAMA Netw Open JAMA Netw Open JAMA Network Open 2574-3805 American Medical Association 37382958 10.1001/jamanetworkopen.2023.20873 zld230106 Research Research Letter Online Only Psychiatry Assessment of Disability and Depression Following Amputation Among Adults in Korea Assessment of Disability and Depression Following Amputation Among Adults in Korea Assessment of Disability and Depression Following Amputation Among Adults in Korea Jung Wonyoung MD MSc 1 2 Kim Miso MD 3 Jeon Hong Jin MD PhD 4 5 Chang Won Hyuk MD PhD 5 6 Yoo Jung Eun MD PhD 7 Han Kyungdo PhD 8 Shin Dong Wook MD DrPH MBA 3 5 1 Department of Family Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Korea 2 Department of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea 3 Department of Family Medicine/Supportive Care Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea 4 Depression Center, Department of Psychiatry, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea 5 Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Science & Technology, Sungkyunkwan University, Seoul, Korea 6 Department of Physical & Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea 7 Department of Family Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea 8 Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea Article Information Accepted for Publication: May 11, 2023. Published: June 29, 2023. doi:10.1001/jamanetworkopen.2023.20873 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Jung W et al. JAMA Network Open. Corresponding Author: Dong Wook Shin, MD, DrPH, MBA, Department of Family Medicine/Supportive Care Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-gu, Seoul 06351, Korea (dwshin.md@gmail.com). Author Contributions: Dr Shin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Jung and Kim contributed equally to this work. Concept and design: Jung, Jeon, Chang, Han, Shin. Acquisition, analysis, or interpretation of data: Jung, Kim, Yoo, Shin. Drafting of the manuscript: Jung, Kim, Jeon. Critical revision of the manuscript for important intellectual content: Jung, Chang, Yoo, Han, Shin. Statistical analysis: Han. Obtained funding: Shin. Administrative, technical, or material support: Jung, Kim, Yoo, Shin. Supervision: Jeon, Chang, Shin. Conflict of Interest Disclosures: None reported. Funding/Support: This research was partially supported by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute and was funded by the Ministry of Health and Welfare, Republic of Korea (grant HI20C1073 to Dr Shin). Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Meeting Presentation: The abstract of this article was presented at the 2023 Spring Conference of Korean Family Medicine Academy; April 14, 2023; Suwon, Korea. Data Sharing Statement: See Supplement 2. Additional Contributions: Bongseong Kim, PhD (Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea), and Hyewon Kim, MD, PhD (Depression Center, Department of Psychiatry, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea), assisted with the analysis and editing of this research. They were not compensated beyond their normal salaries. 29 6 2023 6 2023 29 6 2023 6 6 e232087310 3 2023 11 5 2023 Copyright 2023 Jung W et al. JAMA Network Open. https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the CC-BY License. jamanetwopen-e2320873.pdf This nationwide, population-based, retrospective cohort study assesses the risk of depression following amputation among adults in Korea. ==== Body pmcIntroduction Amputation is a life-changing experience that affects physical ability, body image, quality of life, and stress resilience, all of which are factors associated with depression.1,2 However, most previous studies3,4,5 examining the risk of depression among people with amputation have been conducted in special populations (eg, veterans), confined to traumatic amputation, and limited by cross-sectional designs. Hence, we investigated the risk of subsequent depression after all-cause amputation in this nationwide, population-based, retrospective cohort study in Korea. We hypothesized that amputation might be associated with increased risk of depression, and that this risk could be higher for individuals experiencing disability resulting from amputation. Methods This study was approved by the institutional review board of the Samsung Medical Center and adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. This study enrolled individuals with amputations (aged ≥20 years) and a comparison group matched in a 1:3 ratio for age, sex, and year of amputation using data from the Korean National Health Insurance Service database from 2010 to 2018 (eFigure in Supplement 1). The group with amputations was further categorized on the basis of their disability status and severity (eTable in Supplement 1). The primary outcome was incident depression based on codes from the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). Cox hazard regression models were used to examine hazard ratios (HRs) of depression after adjusting for potential confounders. Additional methods can be found in the eMethods in Supplement 1. Results The cohort consisted of 21 633 individuals with amputations (mean [SD] age, 53.4 [12.1] years; 17 134 men [79.2%]) and 71 895 individuals without amputations (mean [SD] age, 52.8 [11.8] years; 58 054 men [80.8%]). Among individuals with amputations, 40 (0.2%) had a nontraumatic amputation (ICD-10 code Z89; acquired absence of limb), and 21 593 (99.8%) had a traumatic amputation with 1 of the following ICD-10 codes: S48 (shoulder joint; 50 patients [0.23%]); S58 (forearm; 95 patients [0.44%]); S68 (wrist or finger; 20 811 patients [96.20%]); S78 (hip; 30 patients [0.14%]); S88 (knee; 131 patients [0.61%]); or S98 (ankle or toe; 476 patients [2.20%]). Compared with the comparison group, the group with amputations had higher baseline prevalence of smoking, alcohol consumption, rural residency, lower income, and diabetes. This trend was more pronounced among individuals with amputations with a registered disability who also had a higher prevalence of hypertension and dyslipidemia. During a mean (SD) follow-up of 4.9 (2.6) years for people in the amputation group and 5.1 (2.6) years for people in the comparison group, individuals in the amputation group had a 20% increased risk of depression (adjusted HR [aHR], 1.20; 95% CI, 1.15-1.26) after adjusting for potential confounders (Table). Further analysis that classified amputation by disability demonstrated a 17% increased risk of depression in individuals with amputation without a registered disability (aHR, 1.17; 95% CI, 1.12-1.22) and 57% increased risk of depression for individuals with amputation with registered disabilities (aHR, 1.57; 95% CI, 1.40-1.75) compared with the comparison group. In addition, individuals with amputations with mild registered disabilities exhibited a 46% increased risk of depression (aHR, 1.46; 95% CI, 1.29-1.65) and individuals with amputations with severe registered disabilities exhibited a 113% increase in risk of depression (aHR, 2.13; 95% CI, 1.69-2.69). A steep increase in depression incidence (up to 20%) within 2 years after amputation was found in people with severe disabilities (Figure). Table. Risk of Subsequent Depression by Amputation and Disability Statusa Group Age, mean (SD), y Sex, patients, No. (%) Current smoker, patients, No. (%) Heavy alcohol consumption, patients, No. (%)b Diagnosis of depression, No. IR 1000 person-years Model 1, crude HR (95% CI) Model 2, aHR (95% CI)c Model 3, aHR (95% CI)d Male Female Matched comparison group (n = 71 895) 52.8 (11.8) 58 054 (80.8) 13 841 (19.2) 22 812 (31.7) 7841 (10.9) 7447 20.24 1 [Reference] 1 [Reference] 1 [Reference] Amputation group (n = 21 633) 53.4 (12.1) 17 134 (79.2) 4499 (20.8) 7665 (35.4) 2941 (13.6) 2812 26.44 1.31 (1.25-1.37) 1.23 (1.18-1.29) 1.20 (1.15-1.26) Amputation without registered disability (n = 19 990) 52.9 (12.1) 15 736 (78.7) 4254 (21.3) 7096 (35.5) 2704 (13.5) 2471 25.13 1.24 (1.19-1.30) 1.19 (1.14-1.25) 1.17 (1.12-1.22) Amputation with any registered disability (n = 1643) 59.0 (10.8) 1398 (85.1) 245 (14.9) 569 (34.6) 237 (14.4) 341 42.48 2.10 (1.88-2.34) 1.61 (1.45-1.80) 1.57 (1.40-1.75) Amputees with mild registered disability (n = 1360) 59.3 (10.5) 1156 (85) 204 (15) 473 (34.8) 196 (14.4) 269 39.90 1.97 (1.74-2.22) 1.50 (1.33-1.70) 1.46 (1.29-1.65) Amputees with severe registered disability (n = 283) 57.5 (12.1) 242 (85.5) 41 (14.5) 96 (33.9) 41 (14.5) 72 56.03 2.77 (2.20-3.50) 2.22 (1.76-2.80) 2.13 (1.69-2.69) Abbreviations: aHR, adjusted hazard ratio; HR, hazard ratio; IR, incidence rate. a For details on registered disabilities in Korea, refer to the eTable in Supplement 1. b Heavy alcohol consumption was defined as 30 g/day or more. c Model 2 was adjusted for age, sex, and Charlson Comorbidity Index. d Model 3 was adjusted for age, sex, Charlson Comorbidity Index, income, area of residence, diabetes, hypertension, dyslipidemia, smoking, alcohol consumption, and physical activity. Figure. Estimated Incidence Probability of Depression Subsequent to Amputation Figure shows Kaplan-Meier curves displaying the estimated incidence probability of subsequent depression by amputation status (A), by amputation status and registered disability (B), and by amputation status and severity of registered disability (C). Discussion In this cohort study in Korea, we found an increased risk of depression after amputation, emphasizing the importance of disability status and severity in evaluating depression risk among people with amputation. Amputation generates an irreversible physical condition that may lead to feelings of loss of control, which can affect the risk of depression. In addition, depression could lead to further functional disability and poor compliance with rehabilitation.6 Therefore, proactive rehabilitation including psychosocial support for adjustment to amputation is needed. The limitations of our study include its observational design and possible underdetection of depression. To mitigate the potential psychological effects of amputation, it is advisable to conduct screenings and provide psychological support for individuals who are at risk of severe disability resulting from the amputation, particularly during the early stages following the amputation. Supplement 1. eMethods. Supplemental Methods eFigure. Flowchart of Study Population eTable. Definitions of Registered Disability Severity From Amputation eReferences Click here for additional data file. Supplement 2. Data Sharing Statement Click here for additional data file. ==== Refs References 1 Herrera-Moreno D, Carvajal-Ovalle D, Cueva-Nuñez MA, . Body image, perceived stress, and resilience in military amputees of the internal armed conflict in Colombia. Int J Psychol Res (Medellin). 2018;11 (2 ):56-62. doi:10.21500/20112084.3487 32612779 2 Zidarov D, Swaine B, Gauthier-Gagnon C. Quality of life of persons with lower-limb amputation during rehabilitation and at 3-month follow-up. Arch Phys Med Rehabil. 2009;90 (4 ):634-645. doi:10.1016/j.apmr.2008.11.003 19345780 3 Reiber GE, McFarland LV, Hubbard S, . Servicemembers and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: survey methods, participants, and summary findings. J Rehabil Res Dev. 2010;47 (4 ):275-297. doi:10.1682/JRRD.2010.01.0009 20803399 4 Lindner H, Montgomery S, Hiyoshi A. Risk of depression following traumatic limb amputation: a general population-based cohort study. Scand J Public Health. 2020;48 (3 ):289-293. doi:10.1177/1403494819868038 31405332 5 Bhutani S, Bhutani J, Chhabra A, Uppal R. Living with amputation: anxiety and depression correlates. J Clin Diagn Res. 2016;10 (9 ):RC09-RC12. doi:10.7860/JCDR/2016/20316.8417 27790532 6 Roșca AC, Baciu CC, Burtăverde V, Mateizer A. Psychological consequences in patients with amputation of a limb: an interpretative-phenomenological analysis. Front Psychol. Published online May 26, 2021. doi:10.3389/fpsyg.2021.537493 34122200