Prevalence and correlates of depressive symptoms among nurses during COVID-19 pandemic.

Background: During any critical health care situation as COVID-19 pandemic, it is expected that the medical staff will be under a high level of stress. However, nurses specifically are under both physical and psychological pressure during this pandemic, with a risk of mental health problems, such as anxiety and depression. Accordingly, nurses exposed to patients with COVID-19 infection are expected to suffer from a high level of depressive symptoms. This cross-sectional study was applied on 456 nurses with age ranges from 18 to 60. They were divided into two groups: group 1 were composed of 228 nurses who were directly exposed to suspected or confirmed cases of COVID-19 patients, while group 2 were composed of 228 who were less exposed to suspected or confirmed cases of COVID-19 patients for comparison. Data were collected by personal interviews with nurses using Patient Health Questionnaire 9 (PHQ 9) scale for assessment of presence of depressive symptoms and its severity. We aimed to assess the both the prevalence and the predictors of depressive symptoms among nurses exposed to COVID-19 patients. Results: We found a statistically significant higher percentage of depressive symptoms among nurses directly exposed to COVID-19 patients (61.8%) versus the less exposed group (18%). There was a statistically and significantly higher specific COVID-19 associated stressors score (SCAS) among nurses directly exposed to suspected or confirmed cases of COVID-19 patients compared to those who were less exposed; likewise, the PHQ-9 score was a statistically and significantly higher among directly exposed group compared to less-exposed group. Moderate and severe depressive symptoms were present in 23.2% and 22.4%, respectively, within the group of nurses with direct exposure; meanwhile, the less-exposed group showed 7.5% and 3.9%, respectively, with statistically higher significant difference. On doing a linear regression analysis, all the following predictors were significantly independently associated with higher PHQ-9 scores (with higher depressive symptoms severity) among nurses exposed to COVID-19: physical isolation (restrictions on touching others, even after working hours), exposure to a new COVID-19 patient, developing COVID-19-like symptoms, displaying COVID-19-like symptoms by colleagues, knowing that COVID mortality rate exceeds influenza, possible separation from family, concern about family members, fears about infection for patients, family, and friends. Conclusions: COVID-19 pandemic has serious effects on the psychological well-being of nurses exposed to COVID-19 patients. There was an increased rate of depressive symptoms among them during the pandemic with its subsequent burden. Therefore, nurses exposed to COVID-19 patients are in a high need of care and support during the pandemic.

Assessment of compliance and relapse in patients with schizophrenia before and after the onset of COVID-19 pandemic.

OBJECTIVE: The aim of this study was to assess the frequency and correlates of relapse among patients with schizophrenia during the COVID-19 pandemic. METHODS: This retrospective study included 90 adults who met DSM-IV criteria for schizophrenia. The participants were evaluated using Positive and Negative Syndrome Scale (PANSS), Compliance Rating Scale (CRS) and World Health Organisation Disability Assessment Schedule 2.0 (WHODAS 2.0) before and after the onset of COVID-19 pandemic. RESULTS: The mean score of CRS was decreased after the onset of COVID-19 pandemic compared to before COVID 19 ( p < 0.001). The mean total score of PANSS scale and the mean positive subscale (P) score had increased after the onset of COVID-19 pandemic compared to before COVID 19 ( p < 0.001). Following up the news about COVID-19 regularly and decreased level of family support after the pandemic onset were associated with lower CRS scores and higher PANSS scores. In addition, the presence of infection or death with COVID-19 among family members and lower CRS scores were associated with higher scores on PANSS positive subscale. CONCLUSIONS: The relapse rate had increased among patients with schizophrenia during COVID-19 pandemic. Non-compliance with medications and lack of family support were the main correlates of relapse in schizophrenia.Key PointsPatients with schizophrenia are at high risk for relapse during Covid-19 pandemic.Non-compliance with medications, lack of family support, COVID-19-related illness or death of family members and following the news of the pandemic are correlates of relapse in patients with schizophrenia.Psychoeducation, availability of medications and mental health services and family support may help to prevent relapse in patients with schizophrenia during pandemics.Prospective studies are needed to confirm the findings of this study.

Prevalence and determinants of anxiety in patients with epilepsy during COVID-19 pandemic.

Background: Epilepsy is one of the most frequent and serious brain disorders. The nature of the disorder and the unpredictability of seizures usually puts patients in a state of apprehension and anticipation, which creates a continuous condition of anxiety. COVID-19 pandemic has created a state of generalized anxiety all over the world. It is expected that patients with epilepsy (PWE) will suffer from more anxiety during the pandemic. This cross-sectional study was applied on 290 PWE. Data were collected by personal interview with each patient using GAD-7 scale for diagnosing anxiety and assessing its severity. We aimed to assess the prevalence of anxiety and to assess its risk factors in PWE during COVID-19 pandemic. Results: We found that 52.4% of PWE suffered from anxiety. Not working, low financial status, fear of infection and death by COVID-19, fear of job loss, had job changes during pandemic, increased seizures rate during pandemic, increased ER visits, and lack of drug adherence during the pandemic, are significantly associated with increased risk of anxiety. Conclusions: COVID-19 pandemic has a serious effect on the psychological and the physical wellbeing of PWE. There was an increased rate of anxiety during COVID-19 pandemic in PWE with its subsequent burden on those patients. So, these patients are in a high need of care and support during the pandemic.

Prevalence and Correlates of Attention Deficit Hyperactivity Disorder among College Students in Jeddah, Saudi Arabia.

Background: Childhood attention deficit hyperactivity disorder (ADHD) is commonly diagnosed in Saudi Arabia, but there is negligible evidence regarding adult ADHD in college students. Objective: To determine the prevalence and correlates of ADHD among undergraduates at King Abdulaziz University, Jeddah, Saudi Arabia. Methods: In this cross-sectional study, 2280 undergraduate students from 11 colleges at King Abdulaziz University, one of the largest university in Saudi Arabia, were approached in person with a questionnaire that elicited information regarding demographics, education, psychiatric history, health behaviors, and ADHD. A validated Arabic version of the Adult ADHD Self-Report Scale was used. Results: A total of 2059 students (90%) completed the questionnaire (mean age: 21.2 years). Almost one-tenth (11.9%) of the sample met the criteria for adult ADHD; only 6.5% had been diagnosed with ADHD in childhood and <1% (0.8%) had taken medication for the same. Multivariate analyses revealed that high family income, low grade in the last semester, parental divorce, diagnosis of childhood ADHD, prior diagnosis of depression, greater severity of current depression and anxiety, and cigarette smoking increased the likelihood of adult ADHD. Conclusion: A notable proportion of students in this study had suspected adult ADHD. Early evaluation of students with ADHD and identification of those at risk may potentially help in improving their academic performance and quality of life.

Impact of "COVID-19" Lockdown on Male Sexual Behavior in Egyptian Sample.

Objective: To assess the changes in the sexual behavior of Egyptian married men during the COVID-19 lockdown period. Methods: In a cross-sectional study, the sexual behavior of 164 Egyptian married men was examined through an online questionnaire, designed by the authors, and uploaded to strictly male social media groups using Google Forms. The questionnaire included demographic and clinical variables about age, stress level about COVID-19, fear of infection during sexual relations and also compared sexual behavior before the COVID-19 lockdown. Results: 39.17% of the sample reported decrease in sexual desire, 28.05% reported decrease in sexual frequency, 17.68% reported decrease in sexual satisfaction and 22% reported fear of infection with COVID-19 during sexual relations. Severe stress about COVID-19, increased rate of marital conflicts and fear of infection with COVID-19 during sexual relations were significantly associated with decreased sexual desire, frequency and satisfaction. Conclusions: This study demonstrated severe stress about COVID-19, increased rate of marital conflict and fear of infection with COVID-19 during sexual activity, all of which were significantly associated with decreased levels of sexual desire, frequency and satisfaction respectively among married Egyptian men during the COVID-19 lockdown period. Promoting education to manage stress, decreasing marital conflicts and the correction of the mistaken belief that COVID-19 is a sexually transmitted disease is highly important to promote healthy sexual relations during the COVID-19 pandemic and lockdown period.

Depression among health workers caring for patients with COVID-19 in Egypt.

BACKGROUND: Health care workers caring for patients with COVID-19 pandemic are prone to extraordinary stressors and psychological problems. The aim of this study was to estimate the prevalence and risk factors of major depressive disorder among health care providers who are caring for patients with COVID-19. METHODS: Two hundred-seventy of health care workers were screened for depressive symptoms by DASS-21 Questionnaire. Only 152 of the participants accepted to be interviewed using SCID-I for diagnosis of major depressive disorder. RESULTS: According to DASS-21, 28.1% of HCWs had mild-to-moderate depressive symptoms, and 64.8% with severe symptoms. Of 152 who were interviewed using SCID-I, 74.3% were diagnosed with major depression disorder.Young age, decreased sleep hours, female sex, past history of a psychiatric disease, fear of COVID-19 infection for themselves or their relatives, and fear of death with COVID-19 for themselves or their relatives were significant predictors for major depressive disorder and its severity. CONCLUSION: Major depressive disorder is common among HCWs during COVID-19 pandemic. Screening for depression, particularly for young females, and early treatment are recommended.

COVID-19 Infection Stigma Scale: psychometric properties.

BACKGROUND: Stigma has been noticed towards patients with COVID-19 in several regions of the world. This social discrimination has contributed to delay in diagnosis and treatment. Also, it may increase the suffering of the patients leading to poor outcome of the illness. Stigma can be assessed with the use of a valid and reliable instrument developed and adapted to our culture. Our objective was to analyze the psychometric properties of COVID-19 Infection Stigma Scale (CISS) for measuring the social stigma among patients with COVID-19 in Egypt. A cross-sectional study that included 182 COVID-19 patients was carried out. The reliability, the convergent validity, and the external and internal consistency of the scale were measured. Factor analysis was used to exclude the weak items. RESULTS: The mean of the COVID-19 Infection Stigma Scale scores was 34.97±10.35 which was higher than 50% of the score. Absence of the floor and ceiling effects was observed. Cronbach's alpha coefficient for scale reliability ranged from 0.75 to 0.94 with 0.82 for the total score. The convergent validity coefficients ranged from 0.36 to 0.63. Test-retest validity Pearson's correlation coefficients ranged from 0.72 to 0.92 with 0.89 for the total score. The split half correlation coefficient was 0.86, and the reliability coefficient was 0.92. Both were acceptable correlation coefficients for internal consistency of the scale. Factor analysis showed two factors had latent root greater than 1. The rotated component matrix of the 2 factors revealed that all questions had r value more than 0.30, which means that no need to exclude any of them. CONCLUSION: The results showed that the COVID-19 Infection Stigma Scale is a valid and reliable instrument for the Egyptian people. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s41983-021-00317-0.

Female Genital Self-Image in Women With and Without Female Genital Mutilation/Cutting in Jeddah, Saudi Arabia.

INTRODUCTION: The consequences of female genital mutilation/cutting (FGM/C) on female genital self-image are not known. AIM: To assess whether women with and without FGM/C differed with regard to female genital self-image. METHODS: A survey was administered to a group of women attending the King Abdulaziz University Hospital obstetrics and gynecology clinic from December 2016 to August 2017. 963 consecutive adult women seen at the clinic completed the survey. MAIN OUTCOME MEASURES: The main outcome measure of this study was female genital self-image being assessed with the female genital self-image scale (FGSIS). RESULTS: One-fifth (18.2%) of the women self-reported having undergone FGM/C as young girls. Women with FGM/C had a similar FGSIS score as women with no FGM/C (21.3 ± 4.6, n = 175 vs 21.6 ± 4.8, n = 756, analysis of variance, P = .37). In multivariate regression analysis, only level of education remained independently associated with the FGSIS score. Women with some university education had a greater mean FGSIS score than women with no university education (22.1 ± 4.49, n = 564 vs 20.8 ± 5.03, n = 399, P < .0001). CONCLUSIONS: Women with and without FGM/C in a Saudi Arabian clinic generally had a similarly positive genital self-image. Only level of education was independently associated with the FGSIS score. Rouzi AA, Berg RC, Alamoudi R, et al. Female Genital Self-Image in Women With and Without Female Genital Mutilation/Cutting in Jeddah, Saudi Arabia. Sex Med 2020;8:752-756.

Effect of a health-education program using motivational interviewing on oral health behavior and self-efficacy in pregnant women: a randomized controlled trial.

Oral health problems are common among pregnant women. The objective of this study was to examine the effectiveness of motivational interviewing (MI) as a behavior-change technique to enhance self-efficacy and oral health among pregnant women. A randomized controlled trial was conducted with 112 pregnant Iranian women. Women in the intervention group received an education program on oral health using MI during two face-to-face sessions, along with routine health education (two 1-h lectures on oral health changes and needs during pregnancy presented as a lecture by an oral health technician over a 2-wk period). Those in the control group received two 1-h lectures on oral health changes and needs during pregnancy. Oral health behaviors, oral health self-efficacy, and general self-efficacy, were assessed, along with gingival and dental health from baseline to the 3-month follow-up. Analysis of covariance was used to determine differences between intervention and control groups. Scores for both general and specific self-efficacy and for healthy behaviors increased in the intervention group, whereas there was no significant change within controls from baseline to follow-up. Between-group analyses also indicated a significant difference in the scores for self-efficacy and behavior favoring the intervention group. Scores on the gingival inflammation index decreased, as did the number of decayed teeth in the intervention group relative to the control group. The number of filled teeth increased significantly in the intervention group. Health education interventions using MI techniques may help to improve oral health-related self-efficacy and behaviors among pregnant women.

Beliefs of cancer patients in Saudi Arabia.

Objectives: To examine oncology patients' beliefs about the transmissible nature of cancer or its treatments and to determine the correlates thereof.Design: Cross-sectional.Participants: Sixty-nine hospital outpatients completed the questionnaire.Methods: Beliefs about the spread of cancer, chemotherapy, and radiation therapy with physical contact, along with demographic, social, psychological, health-related characteristics were assessed by questionnaire. Bivariate and multivariate analyses identified correlations between these beliefs and patient characteristics.Findings: A percentage (5.8%) believed their cancer could spread like an infection or be transmitted through sexual or nonsexual contact and 15.9% were unsure. Even more (13.0%) believed that chemotherapy could spread through sexual or nonsexual contact and 18.8% were unsure. Likewise, many believed (10.1%) that radiation therapy could spread through sexual or nonsexual contact and 21.7% were unsure. Obsessions with contamination were most strongly associated with such beliefs (B = 0.73, SE = 0.09, p < .0001).Conclusions: Beliefs about the spread of cancer or its treatments are not uncommon in Saudi Arabia, where cultural beliefs and tradition strongly influence healthcare decisions.

Prevalence and predictors of depression among dermatology clinic patients in a teaching hospital, Jeddah, Saudi Arabia.

CONTEXT: Depression in patients with a skin condition can lead to severe consequences that affect the quality of life. To our knowledge, the estimated prevalence of depression in patients who visited dermatological clinics in Jeddah remains unknown. AIMS: To assess the prevalence of depression among patients with dermatological conditions and evaluate the association between clinical and demographic characteristics and depressive symptoms. SETTINGS AND DESIGN: A cross-sectional study was conducted among dermatological patients at King Abdulaziz University Hospital in Jeddah, Saudi Arabia. MATERIALS AND METHODS: The Patient Health Questionnaire-9 (PHQ-9) was used for screening depression. STATISTICAL ANALYSIS USED: Chi-square test and odds ratios (ORs) were used to determine the association among variables. RESULTS: The study included 273 participants. More than two-thirds (194) of the participants were women (71.1%). Depressive symptoms were prevalent in 43 (15.8%) participants. Depression was the most prevalent among patients with psoriasis (39.5%, P < 0.001), followed by those with acne (30.2% P = 0.04). CONCLUSION: Psychosocial assessment should be addressed when evaluating and treating dermatological diseases. Screening tools, including PHQ-9, can facilitate the early detection of depressive symptoms and improve clinical outcomes. Addressing psychosocial aspects of skin conditions may help in reducing exacerbation of symptoms, mainly for conditions aggravated by stress, including dermatitis and psoriasis.

Survey on female genital mutilation/cutting in Jeddah, Saudi Arabia.

OBJECTIVES: The objective of this study was to determine whether female genital mutilation/cutting (FGM/C) exists in Jeddah, Saudi Arabia. DESIGN: A cross-sectional study. SETTING: King Abdulaziz University Hospital, Jeddah, Saudi Arabia. PARTICIPANTS: Between December 2016 and August 2017, women attending the obstetrics and gynaecology clinics were asked to participate in a cross-sectional survey. This included questions on demographics, FGM/C status and type and attitudes towards the practice. RESULTS: In a convenience sample of 963 women aged 18 to 75 years, 175 (18.2%) had undergone FGM/C. Compared with women without FGM/C, women with FGM/C were older, married, non-Saudi and had a lower monthly income. Thirty-seven (21.1%) women had had FGM/C with some cutting of body parts (type I or II), 11 (6.3%) with suturing (type III), 46 (26.3%) with no cutting of body parts (type IV) and 81 (46.3%) did not know their type of FGM/C. There was also a significant association between nationality and age at which FGM/C was performed, with Saudi women undergoing the procedure earlier than Egyptian, Somali, Yemeni and Sudanese women. CONCLUSIONS: FGM/C is prevalent in Jeddah, Saudi Arabia, among immigrant women from other countries, and it is practised among Saudi women. Further research is needed to determine its prevalence.

Effects of a structured heart failure program on quality of life and frequency of hospital admission in Saudi Arabia.

OBJECTIVE:  To compare the quality of life (QOL) and frequency of hospital admission (FHA) in the past 4 months between congestive heart failure (CHF) patients involved in a structured heart failure program (HFP) compared with waitlisted controls. METHODS:   This study, employing an ex-post-facto comparative cross-sectional design, involved 80 patients with CHF (40 in the HFP and 40 controls). Those in the HFP had been enrolled for at least 4 months. Controls were waiting to be enrolled in the program. Participants completed a questionnaire assessing demographic, social/cultural, psychological, and CHF-related physical health characteristics, along with the primary dependent variables, QOL and FHA. Bivariate and multivariate analyses assessed differences between those in the HFP and controls. RESULTS:    Congestive heart failure patients in the HFP were significantly less likely than the control group to score below the median on heart failure-specific QOL, controlling for other variables (OR=0.83, 95% CI: 0.82-0.95, p=0.007). Those in the HFP were also significantly less likely than controls to be hospitalized within the past 4 months (OR=0.78, 95% CI: 0.69-0.88, p less than 0.001). Multivariate analyses indicated that CHF patients in the HFP were 95% less likely than controls to be admitted to the hospital during that period, independent of other risk factors for hospital admission. CONCLUSIONS:  Involvement by patients with CHF in a structured HFP at King Abdulaziz University in Jeddah, Kingdom of Saudi Arabia, is associated with significantly higher quality of life and lower likelihood of being hospitalized compared to CHF patients not involved.

Religiosity and Beliefs About the Transmission of Cancer, Chemotherapy, and Radiation Through Physical Contact in Saudi Arabia.

We examined relationships between religiosity and Saudi cancer patients' beliefs about the spread of cancer, chemotherapy, and radiation therapy through close physical contact. Surveyed were 64 patients seen in university oncology clinics. Assessed were beliefs about the spread of cancer and its treatments, along with religious, demographic, social, psychological, and cancer-related characteristics. Greater religiosity was related to older age, non-Saudi nationality, less anxiety, earlier cancer stage, and greater time since initial diagnosis. Non-significant trends suggested that religious practices were associated with less, but intrinsic religious beliefs with more concern about contagiousness, although the findings were limited by low statistical power.

Religiosity and Telomere Length in Colorectal Cancer Patients in Saudi Arabia.

Numerous studies have reported a significant relationship between psychological stress, depression, and telomere length (TL), an indicator of cellular lifespan. Religious involvement, which is associated with lower levels of stress and depression, has also recently been related to TL. To our knowledge, this relationship has not yet been examined in Muslims, colorectal cancer patients, cancer patients more generally, or any population outside the USA. A convenience sample of 50 colorectal patients was recruited from hospital-based oncology clinics in Jeddah, Saudi Arabia. Religious involvement was assessed with the 13-item Muslim Religiosity Scale. Social and psychological mediators were measured using established scales. TL was determined from whole-blood leukocytes using quantitative PCR technology. Bivariate analyses indicated a positive but nonsignificant relationship between religiosity and TL (r = 0.13, p = 0.35). Controlling for age, did not affect the relationship (B = 15.6, SE = 17.3, p = 0.37), nor did controlling for other demographic, social or psychological factors. Religious involvement was unrelated to TL in this small sample of colorectal patients. Future cross-sectional and prospective studies in different populations with larger samples are needed.

Prevalence of attention deficit hyperactivity disorder and comorbid psychiatric and behavioral problems among primary school students in western Saudi Arabia.

OBJECTIVES: To determine the prevalence of attention deficit hyperactivity disorder (ADHD), subtypes of ADHD, and psychiatric, academic, and behavioral comorbidity in public primary school students in Jeddah, Saudi Arabia.  Methods: This is a cross-sectional study. A simple random sample of 6 primary government schools in Jeddah, Saudi Arabia, was identified (3 male, 3 female), and a random sample of classes in each of grades 1-6 were selected. Between July and November 2016, teachers in these classes were asked to complete the Vanderbilt ADHD scale on all students in their classes.  Results: A total of 929 students were screened. The overall prevalence of ADHD was 5% (5.3% in girls, 4.7% in boys). The most prevalent subtype of ADHD was combined type (2.7%), followed by hyperactive type (1.2%), and inattentive type (1.1%). The highest prevalence of ADHD overall was in grade 3 (7.1%) and the lowest prevalence in grade 6 (3.4%). Among students with ADHD, prevalence of comorbid psychiatric, academic, and behavioral problems was widespread (56.5% oppositional defiant disorder/conduct disorder, 54.4% impaired academic performance, 44.4% classroom behavioral problems, 41.3% depression/anxiety). Comorbid problems were especially prevalent in combined ADHD subtype and in boys. Conclusions: Attention deficit hyperactivity disorder is common in primary school children in Jeddah, and is associated with widespread psychiatric, academic, and behavioral problems, especially in boys. These findings have implications for the diagnosis and treatment of this serious neurobehavioral disorder.

Religious beliefs, practices, and health in colorectal cancer patients in Saudi Arabia.

OBJECTIVE: Colorectal cancer (CRC) patients experience considerable psychological stress because of changes brought on by their illness. Religion may be a resource for such patients. We examined the prevalence of religious beliefs and practices in CRC patients and correlation with demographic, social, psychological, and physical health characteristics. METHODS: Seventy CRC patients (all Muslim) in Jeddah, Saudi Arabia, were surveyed using a 13-item Muslim religiosity scale. Standard measures were used to assess depressive symptoms, depressive disorder, and social support; demographic and social factors, psychiatric history, and disease factors were also measured. RESULTS: All 70 participants (100%) engaged in group worship and prayer (Fard) five times/day, and 75.7% never skipped or combined two or more obligatory prayers; 71.4% read or recited the Qur'an several times/week or daily; 80.0% gave money to the poor each year (Zakat); 71.4% fasted throughout the month of Ramadan (Sawm) and other times as well; 91.4% said they 'definitely' experienced the presence of Allah; and 74.3% said their entire approach to life was definitely based on their religious beliefs. Overall religiosity was inversely related to depressive symptoms (B = -0.58, SE = 0.30, p = 0.026) and suicidal ideation (B = -0.07, SE = 0.03, p = 0.025), after controlling for financial status and social factors. CONCLUSIONS: Religious involvement was widespread in this sample of CRC patients in Saudi Arabia and was related to fewer depressive symptoms and less suicidal ideation. No relationship was found with stage of disease or duration of treatment.

Illness invalidation from spouse and family is associated with depression in diabetic patients with first superficial diabetic foot ulcers.

OBJECTIVES: (1) To assess the prevalence of depressive disorders in a sample of diabetic patients with their first superficial diabetic foot ulcer. (2) To evaluate the association between illness invalidation from spouse, family, and depressive disorders in those patients. METHODS: Depressive disorders and severity were diagnosed by the Structured Clinical Interview for DSM-IV Axis Ι disorders, clinical version, and the spouse and family scales of the Illness Invalidation Inventory, respectively (3*I). Physical functioning was also assessed using the Physical Component of The Short Form 36 item health-related quality of life questionnaire. RESULTS: The prevalence of depressive disorders was 27.50% (22/80). There was a significant decrease in physical health component summary mean score and a significant increase in ulcer size, Center for Epidemiologic Studies-Depression Scale, spouse discounting, spouse lack of understanding, and family discounting mean scores in the depressed group compared to the non-depressed group. Higher levels of spouse discounting, spouse understanding, and family discounting were significant predictors of diagnosis of depressive disorders and were strongly associated with increased severity of depressive symptoms in diabetic patients with first superficial diabetic foot ulcers. Poor physical functioning was associated with increased depressive symptom severity. CONCLUSION: This study demonstrated that illness invalidation from spouse and family is associated with diagnosis of depressive disorders and increased severity of depressive symptoms in diabetic patients with first superficial diabetic foot ulcers.