, Volume 53, Issue 8, pp 1590-1598

First online:

Coping style and depression influence the healing of diabetic foot ulcers: observational and mechanistic evidence

  • K. VedharaAffiliated withInstitute of Work, Health and Organisations, International House, University of Nottingham Email author 
  • , J. N. V. MilesAffiliated withRand Corporation
  • , M. A. WetherellAffiliated withDepartment of Psychology, University of Northumbria
  • , K. DaweAffiliated withDepartment of Social Medicine, University of Bristol
  • , A. SearleAffiliated withDepartment of Community-Based Medicine, University of Bristol
  • , D. TallonAffiliated withDepartment of Community-Based Medicine, University of Bristol
  • , N. CullumAffiliated withDepartment of Health Sciences, University of York
  • , A. DayAffiliated withDepartment of Cellular and Molecular Medicine, University of Bristol
  • , C. DayanAffiliated withHW Labs for Integrative Neuroscience and Endocrinology, University of Bristol
    • , N. DrakeAffiliated withDepartment of Podiatry, Southmead Hospital
    • , P. PriceAffiliated withSchool of Medicine, Cardiff University
    • , J. TarltonAffiliated withMatrix Biology Research Group, University of Bristol
    • , J. WeinmanAffiliated withHealth Psychology Section, Institute of Psychiatry
    • , R. CampbellAffiliated withDepartment of Social Medicine, University of Bristol



Experimental evidence suggests that the healing of diabetic foot ulcers is affected by psychosocial factors such as distress. We examined this proposal in a prospective study, in which we considered the role of psychological distress and coping style in the healing of diabetic foot ulcers over a 24 week period. We also explored the role of salivary cortisol and matrix metalloproteinases (MMPs) as potential mechanisms.


For this prospective observational study we recruited 93 (68 men; mean age 60 years) patients with neuropathic or neuroischaemic diabetic foot ulcers from specialist podiatry clinics in secondary care. Clinical and demographic determinants of healing, psychological distress, coping, salivary cortisol and both MMP2 and MMP9 were assessed at baseline. Ulcers were assessed at baseline and at 6, 12 and 24 weeks post-baseline. The primary outcome was ulcer status at 24 weeks, i.e. healed vs not healed.


After controlling for clinical and demographic determinants of healing, ulcer healing at 24 weeks was predicted by confrontation coping, but not by depression or anxiety. Patients with unhealed ulcers exhibited greater confrontation coping (model including depression: OR 0.809, 95% CI 0.704–0.929, p = 0.003; model including anxiety: OR 0.810, 95% CI 0.704–0.930, p = 0.003). However, change in ulcer size over the observation period was associated with depression only (p = 0.04, d = 0.31). Healed ulcers by 24 weeks were also associated with lower evening cortisol, higher precursor MMP2 and a greater cortisol awakening response.


Confrontation coping and depression predict ulcer healing. Our preliminary enquiry into biological mechanisms suggests that cortisol and precursor MMP2 may underlie these relationships.


Coping Cortisol Depression Diabetic foot ulcers Healing MMPs Prospective Psychological distress