Study Identifies Risk Factors for Suicidal Ideation in Lower Extremity Amputees

Patients with lower extremity amputations have an increased risk of developing suicide ideation, according to results of a study published in Archives of Physical Medicine and Rehabilitation.

Depression screenings are important — especially when dealing with limb loss — to better identify patients who struggle to cope with disability, Aaron P. Turner, PhD, director of Rehabilitation Psychology at the VA Puget Sound Health Care System, and associate professor in the Department of Rehabilitation Medicine, University of Washington, told O&P News.

Individuals with amputation history — especially those who report dissatisfaction with recovery or low self-efficacy — may require additional screenings for suicidal ideation (SI).

Study design

Turner and colleagues examined SI prevalence in 87 patients who underwent lower extremity amputations (LEA) 1 year prior to the study.

The researchers assessed individuals at 12 months post-amputation either through an in-person interview or a telephone interview. Of the 87 individuals evaluated, 70 patients at the 12-month follow-up had complete data in relation to SI. Additionally, the researchers made correlations between variables that were possible risk factors for SI in patients who underwent LEA.

Individuals were evaluated based on demographic information; depressive symptoms, assessed with the Patient Health Questionnaire; depression screenings (proposed by the United States Preventative Services Task Force); comorbidity presence; misuse of alcohol, smoking status, self-rated health, and mobility and mobility satisfaction assessed with the Locomotor Capability Index; satisfaction of ADL; pain; social support; and self-efficacy and SI.


According to the researchers, at 12 months postamputation, SI was statistically significantly related with lower mobility levels, ADL independence, low levels satisfaction of mobility and ADL. Suicidal ideation was statistically correlated with low self-efficacy levels and high depressive symptom levels. When examined together, depression was the most significant risk factor.

Aaron P. Turner, PhD

Aaron P. Turner

The sensitivity was 72.7%, which meant it did not detect all the individuals with SI. Thus, Turner and his colleagues recommended providers specifically ask about SI because asking two depression questions is not always enough to uncover such an important issue.

“When you notice people have more impairment in their activities of daily living (ADL), that they have more difficulty with their mobility [or] when they express dissatisfaction and are unhappy with their state of affairs and have lower beliefs in their own abilities to make things better for themselves — those people may be at higher risk for SI,” Turner said.

Ultimately depression itself was the most significant risk factor for SI.

“I think we understand and have for a long time that depression is highly associated with SI and suicide.”

Additionally, the increasing rates are specifically observed in individuals with amputations due to dysvascular disease. The results confirmed Turner and colleagues’ expectations.

“People who face more challenges in the course of their recovery from limb loss, are unhappy with the progress they are making to meet those challenges and do not feel they have the ability to make things better. It is kind of a trifecta,” he said.

According to the researchers, rehabilitation providers need to recognize risk factors of SI throughout the clinical care they provide.

“There are things providers, family members or loved ones can do to understand what some of the risk factors [are] for SI … that may lead to or be associated with people struggling on that front,” Turner said.

Future research

“Suicide is a tremendously important issue. It is an avoidable mortality outcome,” Turner said. “There are things we do and things we do not have control over as providers, and certainly, the identification of people who may be feeling suicidal is incredibly important because we can provide services to avoid what can be a very unfortunate outcome.”

For future studies, the researchers will include larger cohorts and focus more on the identification of risk factors of self-directed violence in order to improve estimations of SI prevalence. Additionally, they will consider the assessment of other correlates of depression symptoms to better evaluate the development of SI and its contributing factors.

“There are a lot of things that we would still want to know better,” Turner said. “We really only studied SI. We did not study peoples’ suicidal intent, suicidal attempt(s) or actual suicide. SI is the beginning of a chain of events that may lead to suicide and we only looked at the first link in that chain.” – by Monica Jaramillo


Turner AP, et al. Arch Phys Med Rehabil. 2015; doi:10.1016/j.apmr.2015.04.001.

Disclosure: Turner reports no relevant financial disclosures.

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