Investigation and risk factor analysis of anxiety and depression in patients with lower extremity arteriosclerosis obliterans

Abstract

BACKGROUND

The prevalence of lower extremity arteriosclerosis obliterans (LEASO) in China is progressively increasing with the increment in age. Certain patients may be diagnosed with lower extremity arterial stenosis and occlusion that resist complete curative efforts, which will invariably impose a substantial psychological strain on them.

AIM

To investigate the anxiety and depression conditions among patients with LEASO and analyze the associated risk factors.

METHODS

The Affiliated Hospital of Bengbu Medical University from January 2019 to December 2022. Their demographic and clinical data were obtained through the basic information questionnaire. The social support situation was assessed with the social support rating scale, and the hospital anxiety and depression scale were used to analyze their depression and anxiety levels.

RESULTS

The prevalence rate of anxiety was 44.0% among the 159 patients, with a total Self-Rating Anxiety Scale score of 49.01 ± 9.65. The incidence of depression was 40.9%, and the total self-rating depression scale score reached 49.91 ± 9.18. The overall social support score for all participants averaged 24.82 ± 5.80. The correlation analysis between social support scores and anxiety and depression scores revealed that the total social support score, subjective social support, objective social support, as well as the degree of social support utilization, all exhibited a significant negative correlation with the anxiety and depression scores, which was statistically significant (P < 0.05). The univariate analysis revealed statistically significant differences in the depression and anxiety states among patients with varying pain manifestations, disease stages, disease durations, and social support magnitudes (P < 0.05). The multivariate analysis further demonstrated that patients presenting with intermittent claudication, rest pain, and pain, whose disease course was within half a year, and who had relatively low social support, were more predisposed to anxiety. Intriguingly, a monthly income of > 6000 yuan was considered a protective factor in this context (P < 0.05). Similarly, patients with intermittent claudication, rest pain, gangrene, and pain, and who had relatively low social support, were more liable to succumb to depressive moods (P < 0.05).

CONCLUSION

Patients with LEASO typically receive relatively scant social support. Notably, those who concurrently present with symptoms, such as pain, claudication, and gangrene, are at a substantially increased risk of developing depression and anxiety disorders. A significant negative correlation is manifested between the social support level that patients receive and the severity of their anxiety and depression symptoms. Hence, the lower the social support score, the greater the propensity for patients to experience anxiety and depressive emotions. Therefore, during clinical practice, the crucial role that social support plays in safeguarding patients’ physical and mental well-being as well as facilitating the effectiveness of disease treatment needs to be particularly emphasized.

Key Words: Lower extremity arteriosclerosis obliterans; Anxiety; Depression; Social support; Relevance

Core Tip: Individuals with chronic diseases have considerable difficulties that influence their physical and emotional health. They are predominantly known to experience mental health problems more likely than the general population. Anxiety and depression frequently coexist and are typically not distinguished from one another. Hence, the prevalence of anxiety and depression in patients with lower extremity arteriosclerosis obliterans needs to be investigated and the risk factors that contribute to the development of these conditions should be identified.

INTRODUCTION

Arteriosclerosis obliterans (ASO), a condition characterized by atherosclerotic thickening of the arterial wall, loss of elasticity, and medial calcification, causes insufficient blood flow in the lower limbs and consequently results in the arteriosclerotic stenosis or obstruction of the legs[1,2]. Lower extremity ASO (LEASO), as one of the most prevalent forms of peripheral arterial diseases, predominantly presents with ischemic symptoms in the lower extremities[3]. The pathological alterations primarily take place in the intima or media of blood vessels, with secondary thrombosis causing a grave complication[4]. The annual incidence of ASO has been witnessing a steady upward trend in both China and Western countries[5,6]. Concurrently, the prevalence of LEASO in China is progressively rising with the increment in age against the backdrop of rapid economic expansion, dietary restructuring, substantial increase in living standards, and amelioration in healthcare technology qualities[7]. Severe limb ischemia represents the gravest manifestation of this ailment, and any delay in diagnosis and treatment may cause limb amputation or even mortality[8].

Pharmacotherapy, conventional surgical procedures, and percutaneous endovascular therapy constitute the primary modalities for LEASO treatment[9-11]. Some patients require amputation due to severe limb necrosis and infection, pronounced intermittent claudication, rest pain, ischemic gangrene, and persistent nonhealing ischemic ulcers[12]. Further, certain patients may be afflicted with lower extremity arterial stenosis and occlusion that resist complete curative efforts. Moreover, considering that patients with LEASO are frequently accompanied by limited mobility, chronic pain, and incapacity to engage in laborious activities, coupled with a lack of awareness regarding disease-related knowledge and uncertainty about treatment prognoses, this disease invariably imposes a substantial psychological strain on them. Symptoms of anxiety and depression involve predominant psychological manifestations[13]. Ample research has corroborated that psychosocial factors are closely associated with the etiology, clinical manifestations, and prognoses of cardiovascular diseases[14,15]. Depression is an emotional state characterized by somatic and cognitive symptoms, including sadness, a sense of worthlessness, insomnia, loss of appetite and sexual desire, and a reduced level of interest in daily activities[16]. A person who frequently experiences anxiety in high-intensity or inappropriate situations may be diagnosed with an anxiety disorder, including generalized anxiety disorder, panic disorder, phobias, etc[17]. The psychological states of anxiety and depression significantly affect the living and working capabilities of patients with LEASO. Patients with severe diseases may suffer from permanent loss of limb function, which profoundly affects their daily work, study, and life. The majority of them are unable to independently address the difficulties that arise in life, thereby placing a heavy burden on patients and their families. This results in a sense of meaninglessness in life and even causes behaviors such as self-abandonment, self-harm, or suicidal tendencies.

An increasing body of evidence both domestically and internationally has determined mental health problems as risk factors for the development and progression of cardiovascular or other vascular diseases[18,19]. European guidelines have identified depression, anxiety, and psychosocial stress factors, such as work stress or inadequate social support, as vascular risk factors and adverse consequences for patients with existing vascular diseases[20]. Individuals with chronic illnesses have considerable difficulties that affect their physical and mental health. In general, patients with chronic illnesses are more likely to experience mental health problems than the general population[21]. The increasing prevalence of stress, anxiety, and depression among patients with chronic illnesses raises the question of the influence of these illnesses on overall personal health[22]. Chronic diseases tend to have a long illness duration and are associated with high public health expenditures, including pharmacological treatment consumption and a challenging prognosis. Hence, chronic diseases cause severe psychological stress, adversely affect mental health, and are a negative psychological stimulus[23]. Consequently, it is crucial to investigate the current status of depression and anxiety in patients with this disease, identify the risk factors for their occurrence, and implement targeted interventions. This study analyzes the current situation of anxiety and depression in such patients and discusses the factors affecting the occurrence of anxiety and depression by collecting the demographic and clinical data of patients with LEASO to improve their psychological status, boost their quality of life, prolong their survival time, and provide the scientific basis for future clinical practice and clinical teaching.

MATERIALS AND METHODS

Research subjects

Clinical files of patients with LEASO admitted to The First Affiliated Hospital of Bengbu Medical University from January 2019 to December 2022 were collected and retrospectively analyzed.

Inclusion criteria: (1) Definite LEASO diagnosis, with the diagnosis conforming to the internationally commonly used Fontaine clinical staging; (2) Age of 44–74 years; (3) Confirmed LEASO diagnosis by computerized tomography angiography reconstruction and magnetic resonance angiography; (4) Sound language communication, consciousness, and thinking; and (5) Comprehensive and complete clinical data.

Exclusion criteria: (1) Patients presenting with severe infectious diseases; (2) Those who developed septicemia due to severe limb infections; (3) Individuals with a history of depression, anxiety, and mental illness, or a serious family history of mental illness in the second generation of the third line combined with other diseases that seriously affect mental and physical health; (4) Patients who have received anti-anxiety or anti-depression medications; and (5) Those with incomplete clinical data. This study employed a consecutive sampling method; thus, the medical records of patients who met the inclusion criteria were included in the study.

Research methods

Basic data investigation: Using the electronic medical records of patients, we systematically gathered both sociodemographic data, including gender, age, occupation, marital status, and educational attainment, and clinical information, such as disease staging, pain intensity, comorbidities (diabetes and hypertension), and disease duration for patients with LEASO.

Psychological state assessment of patients with LEASO: The self-rating depression scale (SDS) and the self-rating anxiety scale (SAS) were employed to comprehensively examine the depressive and anxious states of patients. The SDS consisted of 20 items, each rated on a 4-point scale of 1-4. To obtain the depression standard score, the sum of all item scores is multiplied by 1.25, and the resulting integer value is obtained. Following the Chinese norm, an SDS standard score of 53 serves as the cut-off value. Scores of 53-62, 63-72, and > 72 indicate mild, moderate, and severe depression, respectively. The SAS, likewise containing 20 items, uses the same 1-4 four-point rating system. The total item score is multiplied by 1.25, and the integer value derived therefrom denotes the SAS standard score. According to the Chinese norm, a cut-off value of 50 is set for the SAS standard score. Scores of 50-59, 60-69, and > 69 indicate mild, moderate, and severe anxiety, respectively.

Social support assessment: The social support received by patients was assessed using the social support rating scale. This scale covers three dimensions: Subjective support, objective support, and support utilization. Comprising a total of 10 items, the scores of items 2, 6, and 7 specifically contribute to objective support quantification. The cumulative scores of items 1, 3, 4, and 5 amalgamate to denote the magnitude of subjective support. Meanwhile, the sum of scores for items 8, 9, and 10 serves to reflect the patient’s proficiency in using available support. In general, the social support level received by patients and the overall social support rating scale score exhibited a direct proportionality between them. More precisely, patients attaining a total score of ≤ 20 points are categorized as having low social support, whereas those achieving a score of > 20 points are deemed to have high social support.

Data processing

Interns from our hospital, who served as investigators, executed the questionnaire survey in this research. Before survey initiation, a comprehensive and standardized training program was meticulously arranged for these investigators. This training aimed to determine the overarching purpose and significance of the survey, the core research elements, and the proper methods and regulations for questionnaire filling. The necessity of obtaining explicit consent from the survey participants before any data collection was especially emphasized. Moreover, the utmost importance was attached to the communication approaches adopted during interactions with patients throughout the survey process. Data entry was conducted using Excel software. To ensure data accuracy, two individuals independently inputted data from each questionnaire. Subsequently, a thorough cross-checking procedure was implemented to detect and rectify any potential input errors, thereby ensuring dataset objectivity and authenticity.

Statistical analysis

Statistical Package for the Social Sciences version 25.0 software was used for all data analyses. Measurement data, such as SDS and SAS scores, were expressed as mean ± SD. An analysis of variance test was initially conducted, followed by a Bonferroni post-hoc test for pairwise comparisons, for comparisons among multiple groups. An independent-sample t-test was applied when comparing the two groups. Categorical variables were described in frequencies and percentages, and group comparisons were conducted using the χ² test. Logistic multivariate regression analysis was conducted to investigate the factors affecting anxiety and depression. A P value of < 0.05 indicated statistical significance.

RESULTS

Patients’ sociodemographic characteristics

A total of 175 questionnaires were distributed, and 159 valid questionnaires were retrieved, with the recovery rate of valid questionnaires at 90.86%. The current survey included male subjects at 50.9% and an average age of 57.93 ± 7.27 years. Regarding educational attainment, 32.7% had completed college education or obtained higher degrees. Geographically, 61.6% of the participants lived in urban areas. The monthly income level was comparatively low, with 23.9% of the total surveyed individuals having a monthly income of < 4000 yuan. The vast majority (51.6%) were married. From a clinical perspective, 37.1% of the patients were in the intermittent claudication stage, and 62.9% demonstrated pain symptoms. Table 1 shows details of participants.

Table 1 Patients’ sociodemographic characteristics.

Characteristics	Number of cases (n = 159)	Composition ratio (%)
Sex
Male	81	50.9
Female	78	49.1
Age (year), mean ± SD	60.55 ± 7.52	-
Body mass index (kg/m2), mean ± SD	23.01 ± 1.65	-
Diabetes	46	28.9
Hypertension	42	26.4
Educational attainment
Junior high school or below	41	25.8
College, technical secondary school, or senior high school	66	41.5
Graduate or above	52	32.7
Marital status
Single	23	14.4
Married	82	51.6
Divorced or widowed	54	34.0
Residence
Urban	98	61.6
Rural	61	38.4
Monthly income (CNY)
< 4000	38	23.9
4000-6000	81	50.9
> 6000	40	25.2
Medical insurance type
Employee or resident basic medical insurance	84	52.8
Commercial insurance	40	25.2
Others	35	22.0
Disease staging
Mild clinical manifestations	59	37.1
Intermittent claudication	59	37.1
Rest pain	36	22.7
Gangrene	5	3.1
Disease course
< 6 months	92	57.9
> 6 months	67	42.1
Pain
Without	59	37.1
With	100	62.9

Anxiety, depression, and social support status

Among the 159 patients with LEASO, the mean scores were calculated as 49.01 ± 9.65 for anxiety symptoms and 49.91 ± 9.18 for depressive symptoms. Considering 50 points as the demarcation for anxiety and 53 points for depression, 44.0% of the 159 patients manifested anxiety symptoms, whereas 40.9% presented with depressive symptoms. The average total score of social support among these 159 patients was 24.82 ± 5.80. To be more specific, the mean scores were 7.61 ± 2.07 in terms of objective support, 9.94 ± 2.86 regarding subjective support, and 7.27 ± 2.09 concerning support utilization. With a cut-off value of 20 points for the total social support score, 67.3% of the 159 patients demonstrated a high social support level, and 32.7% exhibited a low social support level. Table 2 presents detailed information.

Table 2 Anxiety, depression, and social support scores of patients, mean ± SD.

Characteristics	Total score (n = 159)		Score
SAS score	49.01 ± 9.65	Anxiety (n = 70)	57.91 ± 4.15
		Non-anxiety (n = 89)	42.00 ± 6.40
SDS score	49.91 ± 9.18	Depression (n = 65)	58.23 ± 3.44
		Non-depression (n = 94)	44.16 ± 7.29
Total score of social support	24.82 ± 5.80	High social support (n = 107)	28.33 ± 3.20
		Low social support (n = 52)	17.60 ± 1.99
Objective support score	7.61 ± 2.07	High social support (n = 107)	8.59 ± 1.52
		Low social support (n = 52)	5.60 ± 1.54
Subjective support score	9.94 ± 2.86	High social support (n = 107)	11.43 ± 1.93
		Low social support (n = 52)	6.87 ± 1.83
Support utilization score	7.27 ± 2.09	High social support (n = 107)	5.85 ± 1.48
		Low social support (n = 52)	5.13 ± 1.28

SAS: Self-rating anxiety scale; SDS: Self-rating depression scale.

Correlation between depression, anxiety, and social support

Significant correlations were ascertained between the anxiety and depression scores of patients with LEASO and the scores regarding each social support dimension (P < 0.05). Precisely, a negative correlational pattern appeared, signifying that a concurrent and proportional decrease in the total social support score accompanied an incremental increase in depression and anxiety scores. Figure 1 shows a graphical illustration of this association.

Figure 1 Correlation between depression, anxiety, and social support. A: Correlation between self-rating depression scale (SDS) score and total social support rating scale score; B: Correlation between SDS score and objective support score; C: Correlation between SDS score and subjective support score; D: Correlation between SDS score and support utilization score; E: Correlation between self-rating anxiety scale (SAS) score and total social support rating scale score; F: Correlation between SAS score and objective support score; G: Correlation between SAS score and subjective support score; H: Correlation between SAS score and support utilization score. SDS: Self-rating depression scale; SSRS: Social support rating scale; SAS: Self-rating anxiety scale.

Univariate analysis of clinical characteristics of patients with and without anxiety

Among the 159 patients under investigation, 70 manifested symptoms of anxiety. The univariate analysis indicated the presence of statistically significant differences in several aspects, namely monthly income, disease staging, disease course, pain severity, and the social support level between anxiety-stricken patients and those without such symptoms (P < 0.05). Table 3 presents detailed data.

Table 3 Univariate analysis of clinical characteristics of patients with anxiety or not.

Characteristics	Anxiety (n = 70)	Non-anxiety (n = 89)	χ2/t	P value
Sex			1.368	0.242
Male	32	49
Female	38	40
Age (year), mean ± SD	59.74 ± 7.59	61.19 ±7.44	1.207	0.229
Body mass index (kg/m2), mean ± SD	22.86 ± 1.64	23.13 ± 1.65	1.043	0.299
Diabetes	21	25	0.070	0.792
Hypertension	22	20	1.617	0.204
Educational attainment			0.566	0.753
Junior high school or below	16	25
College, vocational school, or senior high school	30	36
Graduate or above	24	28	-	-
Marital status			3.590	0.166
Single	8	15
Married	42	40
Divorced or widowed	20	34
Residence			0.880	0.348
Urban	46	52
Rural	24	37
Monthly income (CNY)			6.033	0.049
< 4000	18	20
4000-6000	41	40
> 6000	11	29
Type of medical insurance			0.107	0.948
Employee or resident basic medical insurance	38	46
Commercial insurance	17	23	-	-
Others	15	20	-	-
Disease staging			15.723	0.001
Mild clinical manifestations	14	45
Intermittent claudication	33	26
Rest pain	20	16
Gangrene	3	2
Disease course			11.531	0.0007
< 6 months	51	41
> 6 months	19	48
Pain			13.171	0.0003
Without	15	44
With	55	45
Social support			17.391	< 0.0001
High social support	40	77
Low social support	30	12

Analysis of influencing factors for the occurrence of anxiety symptoms

Factors exhibiting significant differences in the univariate comparison of anxiety status among the 159 patients were integrated into the multivariate Logistic regression model. The presence or absence of anxiety was considered the dependent variable (0: Absence of anxiety, 1: Presence of anxiety), whereas factors with pronounced differences in the univariate analysis were assigned as independent variables. The regression results demonstrated that an income exceeding 6000 yuan served as a protective factor against anxiety symptoms relative to a monthly income of less than 4000 yuan [hazard ratio (HR) = 0.199, P = 0.015]. The existence of intermittent claudication (HR = 2.983, P = 0.026) and rest pain (HR = 5.359, P = 0.003) were considered risk factors for anxiety with the mild clinical manifestation stage as the baseline. Further, a disease course shorter than 6 months (HR = 3.227, P = 0.009), the presence of pain symptoms (HR = 2.449, P = 0.041), and a low social support level (HR = 7.776, P = 0.000) were all identified as risk factors contributing to the onset of anxiety. Table 4 shows comprehensive information.

Table 4 Analysis of influencing factors for the occurrence of anxiety in patients.

Variable	β	SE	Wald	P value	HR	95%CI
Constant	-2.575	0.625	16.964	0.000	0.076	-
Monthly income (0: 4000 yuan)	-	-	7.058	0.029	-	-
1: 4000-6000	-0.292	0.535	0.298	0.585	0.747	0.262-2.130
2: 6000	-1.613	0.665	5.878	0.015	0.199	0.054-0.734
Disease staging (0: Mild clinical manifestations)	-	-	9.506	0.023	-	-
1: Intermittent claudication	1.093	0.491	4.962	0.026	2.983	1.140-7.805
2: Rest pain	1.679	0.568	8.724	0.003	5.359	1.759-16.326
3: Gangrene	1.020	1.101	0.859	0.354	2.774	0.321-24.007
Disease course (0: > 6 months, 1: < 6 months)	1.172	0.447	6.883	0.009	3.227	1.345-7.745
Pain (0: Without, 1: With)	0.896	0.438	4.192	0.041	2.449	1.039-5.774
Social support (0: High social support, 1: Low social support)	2.051	0.452	20.634	0.000	7.776	3.209-18.842

HR: Hazard ratio; CI: Confidence interval.

Univariate analysis of clinical characteristics of patients with and without depression

Within the cohort of 159 patients examined, 65 presented with depressive symptoms. The univariate analysis revealed statistically significant differences in disease staging, disease duration, pain intensity, and social support levels between patients with depression and those without (P < 0.05; Table 5).

Table 5 Univariate analysis of clinical characteristics of patients with depression or not.

Variable	Depression (n = 65)	Non-depression (n = 94)	χ2/t	P value
Sex			0.129	0.719
Male	32	49
Female	33	45
Age (year), mean ± SD	61.51 ±7.10	59.89± 7.76	1.334	0.184
Body mass index (kg/m2), mean ± SD	22.91 ± 1.61	23.08 ± 1.68	0.663	0.508
Diabetes	20	26	0.181	0.671
Hypertension	20	22	1.072	0.300
Educational attainment			1.416	0.493
Junior high school or below	19	22
College, vocational school, or senior high school	28	38
Graduate or above	18	34	-	-
Marital status			4.163	0.125
Single	5	18
Married	37	45
Divorced or widowed	23	31
Residence			0.000	0.983
Urban	40	58
Rural	25	36
Monthly income (CNY)			4.388	0.112
< 4000	10	28
4000-6000	37	44
> 6000	18	22
Type of medical insurance			0.046	0.978
Employee or resident basic medical insurance	35	49
Commercial insurance	16	24
Others	14	21
Disease staging			33.553	< 0.0001
Mild clinical manifestations	7	52
Intermittent claudication	32	27
Rest pain	23	13
Gangrene	3	2
Disease course			4.358	0.037
< 6 months	44	48
> 6 months	21	46
Pain			13.791	0.0002
Without	13	46
With	52	48
Social support			25.701	< 0.0001
High social support	29	78
Low social support	36	16

Analysis of factors affecting the occurrence of depressive symptoms

Factors that demonstrated significant differences in the univariate comparison of depressive conditions among the 159 patients were incorporated into a multivariate Logistic regression model. The dependent variable includes the presence or absence of depression, with 0 representing no depression and 1 indicating depression. Factors that exhibited significant differences in the univariate analysis were used as independent variables and were assigned appropriate values. The regression analysis results revealed that the presence of intermittent claudication (HR = 8.723, P = 0.000), rest pain (HR = 17.336, P = 0.000), and gangrene (HR = 9.875, P = 0.043) were all risk factors for developing depression, considering the mild clinical manifestation stage as a reference point. Moreover, the presence of pain symptoms (HR = 3.353, P = 0.007) and low social support level (HR = 4.932, P = 0.000) were determined as risk factors contributing to the occurrence of depression. Table 6 presents a comprehensive overview of these results.

Table 6 Analysis of influencing factors for the occurrence of depression in patients.

Variable	β	SE	Wald	P value	HR	95%CI
Constant	-3.764	0.671	31.490	0.000	0.023	-
Disease staging (0: Mild clinical manifestations)	-	-	23.902	0.000	-	-
1: Intermittent claudication	2.166	0.537	16.280	0.000	8.723	3.046-24.981
2: Rest pain	2.853	0.611	21.795	0.000	17.336	5.234-57.424
3: Gangrene	2.290	1.132	4.091	0.043	9.875	1.074-90.838
Disease course (0: > 6 months, 1: < 6 months)	0.514	0.429	1.432	0.231	1.671	0.721-3.877
Pain (0: Without, 1: With)	1.210	0.451	7.185	0.007	3.353	1.384-8.120
Social support (0: High social support, 1: Low social support)	1.596	0.433	13.581	0.000	4.932	2.111-11.526

HR: Hazard ratio; CI: Confidence interval.

DISCUSSION

Extensive research has revealed that depression and anxiety are likely to have profound implications on the progression and onset of lower extremity arterial occlusion in patients, operating through a multiplicity of pathways. In particular, negative emotions, such as depression and anxiety, bear a direct association with deleterious health behaviors among patients, including excessive alcohol consumption, smoking, erratic dietary patterns, and an aversion to physical exercise engagement. These behaviors, in turn, conspire to markedly improve the patients’ susceptibility to cardiovascular ailments[24,25]. Consequently, closely monitoring the anxiety and depression statuses of these patients is not only advisable but essential. In the present study, among the 159 patients with LEASO, 44.0% demonstrated anxiety symptoms and 40.9% had depression symptoms. This indicates that > 40% of patients with lower extremity arterial occlusion concurrently endure depression and anxiety. These results have been corroborated in other studies. Some investigations have revealed strikingly increased depression and anxiety prevalence in patients afflicted with the disease, with a prevalent occurrence of coexisting depressive and anxiety disorders. In severe depression and anxiety cases, patients may not only face a high risk of suicide but also experience significant impairments in their physical functions[26]. Therefore, we further investigated the clinical and demographic characteristics of patients with LEASO who developed depression and anxiety, aiming to determine the main risk factors.

The univariate analysis of affecting factors for anxiety in patients with LEASO identified monthly income status, disease staging, disease duration, the presence or absence of pain, and the adequacy of received social support as the variables with statistical significance. Meanwhile, the univariate analysis for depression determined disease staging, disease duration, the presence or absence of pain, and the adequacy of social support obtained as significant variables. Further multivariate regression analysis revealed that a monthly income exceeding 6000 yuan served as a protective factor against anxiety symptoms. In contrast, the presence of intermittent claudication and rest pain, a disease course of less than half a year, the existence of pain symptoms, and a low social support level were all identified as risk factors predisposing patients to anxiety. Lower extremity arterial ischemia represents the main clinical symptom in patients with LEASO. Specifically, stage I of the disease is characterized by mild symptomatology, whereas stages II-IV manifest successively as intermittent claudication, rest pain, and gangrene, with patients’ symptoms progressively worsening. Notably, the pain experienced by patients is predominantly continuous and demonstrates exacerbation during the nocturnal period. Patients are rendered more susceptible to the development of depressive and anxious emotional states under the protracted duress of persistent pain and the compounding influence of limb impairments. The disease course of LEASO is typically protracted. Hence, the psychological resilience of patients with LEASO gradually strengthens over time, with superior psychological elasticity compared with newly diagnosed patients. Conversely, under the combined stressors of the newly diagnosed condition, the occurrence of disease-related pain, and limb impairments, patients within the first half-year of the disease course are more prone to developing anxiety[27]. Beyond the physical pain caused by the disease, the clinical symptoms associated with LEASO affect patients’ work and daily lives. The financial pressure stemming from treatment costs and potential income suspension renders low-income patients more susceptible to anxiety. Consequently, a relatively increased income could potentially function as a protective factor against anxiety. Moreover, social support is a well-recognized protective factor against mental disorders[28]. Isolation and a lack of family or peer support should be regarded as “warning signs”. Patients with low social support levels may feel isolated and helpless psychologically, which triggers or exacerbates anxiety and depression. Further, the present study ascertained that both depression and anxiety scores of patients exhibited a significantly negative correlation with the total social support score and the scores of its respective dimensions. Precisely, a lower social support level corresponded to higher anxiety and depression scores. The analysis of the depressive and anxious states among patients with LEASO further revealed no statistically significant differences across genders, age brackets, and marital statuses. Some research has indicated an association between educational attainment and anxiety or depression. Patients with a higher educational background typically attach greater significance to social and family functions, harbor increased self-expectations, possess improved emotions, rich imagination, and broad thinking dimensions, and thus are frequently burdened with excessive concerns and anxieties. In brief, the higher their educational attainment, the more significant the social and family functions become, and consequently, the more prominent the anxiety and depression symptoms[29]. However, this study did not arrive at a similar conclusion. It is potentially attributable to the relatively small sample size and the relatively even patient distribution across various educational levels, causing an insignificant difference.

This study still has several limitations. The small study population was considered a major limitation. Further, the implementation of this study as a single center reduces its generalizability. Furthermore, retrospective secondary data analysis carries the risk of information bias, especially with incomplete documentation in these kinds of research. A well-designed, randomized, and controlled trial with prospective data collection and sample size calculation is warranted to confirm the findings of our study.

CONCLUSION

To sum up, patients afflicted with LEASO demonstrate a predisposition to developing depressive and anxious moods. Notably, patients whose disease has progressed to advanced stages, manifested by symptoms, such as intermittent claudication and gangrene, as well as those experiencing pain and receiving limited social support, face an increased risk of succumbing to depression and anxiety. Clinically, we should strengthen the psychological screening of patients with chronic cardiovascular disease. Treatment plans can be tailored and interventions can be implemented based on the actual disease staging and pain condition of patients. Mental health services need to be provided when the patient may have anxiety or depression. Moreover, family members should be motivated to provide more encouragement and support to patients, enabling them to maintain an optimistic mindset. Such measures would assist patients in allaying their concerns, gaining a better understanding of their condition, and establishing healthy behaviors and lifestyles, thereby reducing disability rates and improving the quality of life.