By Ryan Cummings, FNP, CWS

Although the impact of depression on all aspects of health and healing is well known and has been researched in progressively greater detail over the last decade, the role depression plays in prolonging healing time in chronic wounds is still rarely addressed fully. Empirically, every wound care provider has witnessed depression in patients with chronic non-healing ulcerations, although rarely is this directly addressed in wound care training or in algorithmic treatment plans.

Ongoing pain, odor, body image compromise, and lack of faith in one’s own ability to heal are only some of the issues that wound care patients are often forced to address, and we owe it to our patients to be prepared to both discuss and validate their experiences during their time in our care. If the greatest single factor in positive wound outcomes is patient concordance with and adherence to a plan of care, depression necessarily must be viewed as a formidable obstacle.

Behavioral cornerstones of healing include patient engagement, appropriate nutrition, appropriate rest, and stress reduction. The chronically depressed patient commonly presents with reduced appetite, early morning awakening and/or reduced quality of sleep, poor focus, and lack of interest in learning. How much of patient apathy or non-concordance could and possibly should be more correctly attributed to an underlying depressive state? If we find ourselves more comfortable discussing depression with our patients routinely, imagine the potential impact it could have on patient ownership of care, increased healing rate, reduced time to heal, and overall quality of treatment.

The Effect of the COVID-19 Pandemic

The onset of the COVID-19 health crisis has resulted in greater social awareness of the toll of depression and isolation, and in some senses this pandemic has reduced the stigma associated with patient acknowledgment of depressive symptoms. This in turn has given providers outside the primary care setting a bit more practice–and hopefully greater comfort—with conversations regarding mood, mental health, and the importance of treatment if warranted. Wound care providers occupy a unique place during this crisis because in many cases the wound specialist may very well be the only person a patient interacts with regularly, as a result of COVID-19 restrictions. Similarly, the serial nature of wound clinic visits provides an opportunity to develop a positive rapport, easing potential discomfort in discussing depression.

Screening Questionnaire and Questions

In initial patient assessments, broaching the topic of depression can be challenging for providers who don’t regularly do so, and administering a routine Patient Health Questionnaire (PHQ-9),¹ although helpful, may not be possible in all outpatient clinic settings. However, a robust wound care practice that carefully evaluates factors relevant to healing very likely includes asking about nearly every question in this screening tool already. All we need to do as providers is to correlate the information we’ve been provided. For those who are unfamiliar with it, the PHQ-9 is a routine screening tool used to allow patients to self-identify symptoms of depression. Inquiries about activity level, sleep, and nutrition are pivotal to a good plan of care, and modifying these questions to identify potential risk for depression is relatively simple. Some possible examples are listed here:

• Do you have hobbies? If so, what are they? How often have you been doing these things?
• How much are you sleeping lately? Do you feel rested when you wake?
• What’s your energy level like?
• How’s your mood?
• Has anyone around you noticed changes in your behavior?
• Do you feel you’re able to concentrate?
• How do you feel your wound is impacting your life? Do you feel positive about yourself?
• How is your appetite? Are you eating three meals daily?
• Have you recently had thoughts of self-harm?

If the patient’s answers imply a change in function or indicate depression, administering a formal PHQ-9 at that time would be helpful in formulating a plan of care, which may include consultation with the patient’s primary care provider, supportive discussion during care, or possible referral to behavioral therapy, depending on the severity of the symptoms.

Benefits of and Tools for Discussing Depression

A variety of factors can contribute to provider hesitance in discussing depression, including lack of familiarity with the disorder or the perception that it would be too time consuming in a busy practice setting, but research shows that depressed patients benefited from even brief discussions of their symptoms and concerns with providers who demonstrated encouragement and a positive demeanor,² For information about mental health resources in individual communities, the Substance Abuse and Mental Health Services Administration website (www.samhsa.gov) contains tools for locating care, as well as additional provider training for identifying and managing depression.³

References

1. Patient Health Questionnaire (PHQ-9). Overview and scoring. https://www.drugsandalcohol.ie/26814/1/Patient%20Health%20Questionnaire…. Accessed April 13, 2021.

2. Percival J, Donovan J, Kessler D, Turner K. “She believed in me.” What patients with depression value in their relationship with practitioners. A secondary analysis of multiple qualitative data sets. Health Expect. 2017;20(1):85-97. doi:10.1111/hex.12436.

3. Substance Abuse and Mental Health Services Administration. Clinical support system for serious mental illness. 2021. https://www.samhsa.gov/clinical-support-system-serious-mental-illness-c…. Accessed April 13, 2021.

Additional Resource

Brooke, C. Communication with depressed patients. Elsevier Clinical Skills. 2017. https://www.elsevierclinicalskills.co.uk/SampleSkill/tabid/112/sid/1737…. Accessed April 13, 2021.

About the Author

Ryan Cummings is a family nurse practitioner and certified wound specialist with a ten-year history of wound care experience, including home health, hyperbaric medicine, inpatient and outpatient wound management. He has also worked extensively as a wound educator and clinic manager, and most recently became involved in the international society of pediatric wounds as one of very few dedicated outpatient pediatric wound specialists. He possesses an intense passion for patient care and the advancement of wound science to both enhance the practice of wound healing and to improve patient outcome and quality of life.