Vol.2, No.8, 878-889 (2010)
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Depression in adult males with lower extremity amputa-
tion and its bio-social correlates
Arupendra Mozumdar1, Subrata K. Roy2*
1Department of Health, Nutrition and Exercise Sciences, North Dakota State University, Fargo, USA;
2Biological Anthropology Unit, Indian Statistical Institute, Kolkata, India; *Corresponding Author: rsubrata@isical.ac.in
Received 23 March 2010; revised 30 April 2010; accepted 2 May 2010.
Depression is often associated with many adverse
health conditions and lower socio-economic
status. Stressful conditions like presence of
disability coupled with traditional negative so-
cietal attitude towards disability may result in
higher level of depression in the individuals
with disability than in general population and
can cause other health problems as well. There-
fore, the purposes of this study are to explore
the association of depression with its biosocial
correlates among individuals with lower ex-
tremity amputations (LEA) living in Kolkata, In-
dia. Eighty-five participants with traumatic LEA
and 105 control participants with no amputation
participated in this study. The depression levels
of the participants were measured with Beck
Depression Index (BDI). All participants were
also measured with the following sets of health
traits, using standard techniques1) physical:
body weight, stature, body mass index (BMI),
blood pressure, total cholesterol, triglycerides,
blood glucose, hemoglobin%, 2) functional:
functional outcome or degree of independence
in daily activities, and 3) social: economic con-
dition, and social discomfort. No significant
difference was found in mean BDI scores for
individuals with LEA and control participants.
Higher BDI scores were associated with chronic
energy deficiency. None of the other physical
health traits was associated with depression
level. Higher depression was associated with
poor socio-economic conditions like low eco-
nomic condition, dependency on others for daily
activity, occupational constraints due to disabil-
ity and perceived problems in conjugal life.
Therefore, economic development with a posi-
tive social attitude toward people with disability
is essential for the mental wellbeing of the indi-
viduals with LEA.
Keywords: Depression; Biosocial Health Factors;
Lower Extremity Amputation
Depression is a mental state characterized by feelings of
sadness, with downturn mood in despair and discour-
agement, loss of interest or pleasure, a pessimistic sense
of inadequacy and a despondent lack of activity, feelings
of guilt or low self-worth, disturbed sleep or appetite,
low energy, and poor concentration [1]. However, de-
pression is often considered as a medical disorder, like
any other physical disorder, which affects human thoughts,
feelings, behaviors and even physical health (e.g. weight
loss, loss of appetite, loss of sleep, loss of libido, etc) [2].
Symptoms of depression may be the outcomes of pro-
longed exposure to the stressful life conditions. Negative
consequences in life (like disease and disability) not only
make life stressful, but also adversely affect the adaptive
resources (which is very much dependent on the
socio-economic condition of a given individual). Lower
extremity amputation (LEA) cause serious physical dis-
ability and it is intuitive that adjustment to the conditions
of amputation is impulsive to psychological distress.
Depression in individuals with LEA was well investi-
gated and many studies reported the prevalence rate of
depression up to 45% among the study samples [2-8].
The individuals with LEA showed relatively higher
mortality rates due to cardiovascular diseases than the
general population [9-12]. A number of studies investi-
gated and inferred a close relationship of depression with
high blood pressure [13-15], diabetic condition [16],
high cholesterol level [17-21], and obesity [22,23]. From
the above-mentioned studies, it may be argued that the
individuals with LEA generally suffer from greater car-
diovascular risks, and may also suffer from depression,
although there is a dearth of empirical study among the
individuals with LEA in this regard.
A. Mozumdar et al. / HEALTH 2 (2010) 878-889
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Several studies revealed that major depressive disor-
ders and greater depressive symptomatology were more
prevalent at lower levels of socioeconomic status [24,
25]. However, income levels of people with an amputa-
tion were not related to depressive symptoms [26].
A number of studies showed that people generally
avoid interaction or are likely to terminate an interaction
sooner with a person who has visually detectable dis-
ability, when a socially acceptable excuse is available
[27,28]. People with an amputation also reported the
same experiences. Therefore, the individuals with LEA
have to adjust to the reality that they appear ‘different’
from other people [29]. The social problem often en-
hances due to movement restriction, coupled with poor
health, which in turn often limits opportunities for social
participation such as regular walking outside, keeping
contact with loved ones and acquaintances, and in-
volvement in social ceremonies [30]. The findings of
earlier studies regarding the impact of an amputation on
social functioning were mixed. Some studies reported no
significant difference in social functioning or levels of
social discomfort between those with and without am-
putations [31-34]. Contrary to these finding, several
quantitative studies demonstrated the association of in-
creased social isolation and lower levels of perceived
social support with lower perceived quality of life and
higher levels of depressive symptomatology among peo-
ple with amputation [5-7,35].
Amputation level appears to be an important factor
predicting successful rehabilitation [36]. Williamson
[37], and Williamson and Walters [38] reported the dif-
ference in the levels of activity among individuals with
different levels of LEA. Many authors studied the rela-
tionship of levels of amputation and the mental health of
the individuals with LEA [26,35,39-41]. Gerhards et al.
[42], and Cansever et al. [43] indicated association of
depression with the cause of the amputation. Horgan and
MacLachlan [44] studied the relationship of depression
of the individuals with LEA with their functional out-
come as well as their duration of disability.
The mental health of the individuals with a physical
disability is often influenced by the attitude of the soci-
ety towards physical disability. The attitude of the soci-
ety towards people with disability is different in tradi-
tional society from the modern Western world, where the
attitude mostly changed after World War II. The welfare
efforts for people with a disability were changed from
providing the life sustenance, towards improving all-
round social well-being, considering people with dis-
abilities as productive members of the society. In the
developing world, particularly in traditional societies,
attitudes are changing at a much slower pace [45].
In India, traditionally the rehabilitation of people with
a disability was considered to be a responsibility of the
family and local communities. The1980s changed the
scenario significantly. As a signatory to the World Pro-
gramme of Action Concerning Disabled Persons, India
had also developed the Persons with Disabilities Act
1995 [46]. The objectives of the act are directed towards
creating a barrier-free environment for people with a
disability; and towards their self-reliance and socio-
economic development. Along with other efforts, a per-
centage of public sector job are also reserved for the
persons with a physical disability. However, still the
Indian society is in a crossroad between the positive and
negative attitude towards physical disability. This paves
a unique consequence for the mental and social health
status of the people with a disability, certainly different
from that of modern Western society.
In view of these, the objectives of the present study
are the following in the individuals with lower extremity
amputation (LEA) from Kolkata, India1) Can the
condition of locomotor disability enhances depression? 2)
What is the relationship of depression with selected
health traits? 3) What is the relationship of socio- eco-
nomic condition with depression? and 4) Is there any
relationship of disability related factors (e.g. duration of
disability, level of disability, and use of prosthesis, etc.)
with depression?
2.1. Population and Sample
The data were collected as a part of a larger bio-medical
program involving individuals with a lower extremity
amputation from Kolkata and its adjoining areas. Two
national level rehabilitation centers, the National Insti-
tute for the Orthopedically Handicapped and Mahavir
Seva Sadan were contacted for a list of addresses of the
individuals with an amputation. A statement of purpose
of the study and a consent form seeking their participa-
tion were mailed to about 1000 adult male individuals
with unilateral LEA. It is well documented that the pre-
valence rate of locomotor disability in adult males is
higher than females in India [47], which was one of the
reasons for considering only males as participants. Re-
spondents (109 individuals), with written consent, were
included in the study. Although the response rate was
very low, it was the most convenient way to recruit the
samples, as maintenance of hospital records was very
poor and absence of any data-bank for people with dis-
ability. Due to death or severe illness or migration, there
were few dropouts during data collection, leaving 102
individuals with LEA. Most of the study participants
experienced traumatic amputation (82.6%). Degenera-
tive diseases like diabetes (11.0%) and cancer (6.4%)
A. Mozumdar et al. / HEALTH 2 (2010) 878-889
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were the other two common causes for amputation. For
this study only the individuals with traumatic amputation
(n = 85) was considered, because the depression level of
individuals with LEA due to diabetes or cancer may not
have a similar level of depression from that of an indi-
viduals with a traumatic amputation.
Out of 85 individuals with traumatic amputation, 27
individuals had above-knee amputation and 58 individu-
als had below-knee amputation. The mean age of the
study participants (individuals with traumatic LEA) was
42.58 ± 14.81 years. All participants had prosthesis and
all of them had been amputated at least approximately 2
years prior to the study. As there is a lack of any estab-
lished population norm for depression level in the study
population, a number of 105 non amputated healthy males,
matched for age and socio-economic status (mostly from
among the close-kins of the individuals with LEA) were
studied as control group. All the study participants i.e.
individuals with limb amputation and all the control
group participants, were Bengali-speaking Hindus. All
data were collected by a single investigator (AM) through
multiple home visits. The study was done in accordance
with the responsible committee on human experimenta-
tion (Scientific Ethical committee for Protection of Re-
search Risks to Humans) at the Indian Statistical Insti-
tute, Kolkata.
2.2. Data Types
2.2.1. Measurement of Depression
All participants were screened for the presence of de-
pression using the Beck Depression InventoryII (BDI)
[48]. The BDI is one of the most commonly used meas-
ure of depression, and its reliability and validity has been
assessed in a variety of study populations [48] including
individuals with disability [49-52]. The Beck Depression
Inventory is a self-report questionnaire consisting of 21-
items/ questions. Each question has a set of at least four
answer choices, ranging in intensity. For example, the
item concerning mood had five answers:
(0) I do not feel sad.
(1) I feel sad.
(2a) I am blue or sad all the time and I can’t snap out
of it.
(2b) I am so sad or unhappy that it is very painful.
(3) I am so sad or unhappy that I can't stand it.
While completing the BDI, for each item the partici-
pants were asked to select at least one answer from the
list of given answers. Upon completion of the answering
all items, a value of 0 to 3 was assigned for each answer
and the scores of all 21 answers were summed up.
Therefore, every individual had a theoretical possibility
of scoring 0 to 63. If a participant selected more than one
answer for any item, then the highest scoring answer was
considered. As the participants of this study were from a
non-English speaking population, a translated and well-
tested Bengali version of the BDI scale was used [53].
Regarding the BDI test scores and interpretation, the
following scores and interpretive labels were used to
characterize scores on the BDI-II as: 0-13 (minimal), 14
-19 (mild), 20-28 (moderate), and 29-63 (severe) as
suggested by Beck et al. [48]. Since there is no cut-off
value specifically for the study population the cut-off
values proposed by Beck et al. [48] was used.
2.2.2. Measurement of Physical Health Traits
The traits considered in the present study for biological
response of the depression were systolic and diastolic
blood pressure, hemoglobin %, blood glucose, total cho-
lesterol, triglycerides and body mass index. Data on all
the measurements were collected following standard
techniques as recommended by the International Bio-
logical Program (IBP) [54]. Body weight of the indi-
viduals with an amputation was calculated using the
formulae of Mozumdar and Roy [55]. Body mass index
was calculated using the formula bodyweight (Kg)/
height (M)2. Waist circumference measurement was
taken at the iliac crest level. Blood pressure measure-
ments, systolic blood pressure (SBP) and diastolic blood
pressure (DBP), were taken after a 15 minute rest period,
in a sitting position on the left hand by the auscultatory
method using a mercury sphygmomanometer and a ste-
thoscope. The traits involving blood analysis were done
by collecting blood samples by finger pricking, followed
by putting the blood drops on different strips meant for
different traits. All the blood parameters were analyzed
immediately after collecting the blood samples from the
participants with a dry autoanalyzer (Accutrend-GCT
manufactured by Borhinger-Mannheim, 1999) and the
respective results were recorded subsequently.
2.2.3. Measurement of Economic Condition
Data on monthly family expenditure were collected from
the participants and monthly per capita expenditure
(MPCE) was calculated. However, MPEC was not used
in this study to indicate the economic condition of the
participants as other studies among the general popula-
tion of the study location had experienced some un-
avoidable errors of under- or over-reporting of MPCE.
Therefore, an alternative and more objective method was
used to assess the economic condition of the participants.
This method had widely been used by Bhattacharya,
Chattopadhyay, and Rudra [56] and Chattopadhyay [57]
in many published literatures. In this method, the ratio
between the number of living rooms in the household
and number of family members (household size) (i.e.
number of living rooms in the household/household size)
were calculated. Then the participants’ families were
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classified into three economic categories: low, middle, or
high. If the ratio was 0.25 or less, i.e. at least four
household members were living in one family living
room (in most cases a couple with their two children),
the economic category of the family was classified as
‘low’. Similarly, if the ratio was higher than 0.25 but less
than or equal to 0.5, i.e. at most two household members
were living in a single room, the economic category of
the family was considered as ‘middle’. If the ratio was
higher than 0.5, i.e. on average rooms in the house were
shared by less than two persons, the economic categories
of the family were considered as ‘high’. This classifica-
tion of economic condition was also in agreement with
MPCE of the participants. Out of 85 participants with
amputation, 29 individuals belonged to the low eco-
nomic group, 30 individuals belonged to the middle
economic group and 26 individuals belonged to high
economic group.
2.2.4. Measurement of Social Discomfort
The social discomfort level for each participant was
measured using the Social Discomfort Scale (SDS) as
used by Rybarezyk et al. [5] in their study. SDS is a
3-item questionnaire and each question focused on the
extent of discomfort in social interactions associated
with an individual with an amputation. For example:
“Does it bother you to have an adult you don’t know ask
you about your amputation or prosthesis?” Each SDS
item has three answers‘1–not at all’, ‘2–somewhat’,
and ‘3–definitely’, assigned scoring was 1 to 3. There is
a possibility of scoring 3 to 9 in SDS. Score ‘3’ indicates
absence of any social discomfort and score ‘9’ indicates
the highest degree of social discomfort.
2.2.5. Measurement of Functional Outcome
The Locomotor Index (LI) was used to measure the mo-
bility and personal independence of a participant with an
amputation. LI has widely been used for its reliability
and sensitiveness for the measurement of personal inde-
pendence of an individual with an amputation [9,58]. LI
is a 14-item questionnaire with 4-multiple choice an-
swers for each item, regarding the nature and extent of
dependency in movement as well as daily activities. The
scale ranges from 0 to 3 for each item/question, giving
the possible range of scoring from 0 to 42 for all 14
items/questions. The scoring of ‘42’ indicates the indi-
vidual is fully independent in daily activities, while a
score of ‘0’ indicates a total dependence of the individual
with an amputation on others. It is worthy to mention
that if a participant with LEA reported to perform certain
daily activities with the help of his rehabilitative aid (e.g.
prosthesis or crutch), he was still considered independent
for such activities, unless he was reported to take help
from another person.
2.3. Statistical Analysis
Demographic characteristics of the participants with
LEA and the control participants were presented and
compared by calculating Chi-square tests. The distribu-
tion of the levels of depression among the individuals
with LEA and controls were presented using the standard
cut-off values for BDI scores [48]. The descriptive sta-
tistics of the BDI scores were calculated for the indi-
viduals with LEA and for the control group as well. Fur-
ther, the comparisons between the two groups were done
using independent sample t-tests. As there were a lack of
published literatures reporting comparison of BDI score
between individuals with traumatic amputation and con-
trol population, no pre-test power analysis was done.
Therefore, a post hoc power analysis was done by cal-
culating the effect size (Cohen’s d) and the statistical
The participants with LEA were classified according
to the presence or absence of a number of health risk
factors. The different risk factors with their respective
cut-off values were presented. The descriptive statistics
of the BDI scores were calculated for the participants
with LEA separated by presence or absence of the health
risk factors. Subsequently, comparisons of BDI scores
between the two groups have been done for each health
risk factor.
The relationship between the presence of locomotor
disability and the physical health traits were examined
by a two-way analysis of variance of BDI scores, using
the presence of LEA as a fixed factor and each physical
health trait as a covariate. The same analysis was also
done to determine the relationship between depression
level and the economic condition (ratio between number
of rooms in household and household size) of the indi-
viduals with LEA. The relationships between depression
level and various disability related factors were exam-
ined by applying logistic regression analysis. All statis-
tical analyses were done using the software SPSS for
Windows version 14.0.
On average the participants were middle aged (nearly
44% between 40 years to 55 years), married (65.7%), and
with a secondary level of education (58.8%) (Table 1).
About 50% of the participants with LEA belonged to
households with annual per capita expenditure between
$200 and $400. Comparisons of the demographic char-
acteristics between the participants with LEA and con-
trol participants were done using chi-square tests. The
distribution of the participants across age groups, per
capita expenditure categories, economic conditions,
marital statuses and education levels were similar be-
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tween the two groups. There was a significant difference
in occupation types between the two groups. Most of the
full-time workers with LEA were employed in public
sector jobs. The unemployment rate was also high
among the individuals with LEA in comparison to con-
trol participants.
Nearly 50% of the individuals with LEA had a ‘mini-
mal’ level of depression, whereas control participants
with a ‘minimal’ level of depression were in a higher
percentage (56.2%) (Table 2). The percentages of other
Table 1. Socio-demographic characteristics (in %) of the participants with LEA and controls and the comparisons between the two
groups (The p values indicate the results of Chi-square tests).
Part. with LEA Controls
n = 85 n = 105 p
Age group
20-24 years 10.59 7.62 0.61
25-29 years 11.76 18.10
30-34 years 8.24 10.48
35-39 years 9.41 9.52
40-44 years 18.82 10.48
45-49 years 14.12 10.48
50-54 years 10.59 8.57
55-59 years 2.35 7.62
60-64 years 2.35 4.76
65-69 years 5.88 6.67
70 years and more 5.88 5.71
Annual per capita expenditure in household (1 US$ ~ 40 INR)
Below $200 35.29 20.95 0.09
$200–below $400 45.88 56.19
$ 400 and more 18.82 22.86
Economic condition (No. of Room: household size (N/H)
Low = N/H < 0.25 34.12 26.67 0.37
Medium = N/H > 0.25 > 0.5 35.29 44.76
High = N/H > 0.5 30.59 28.57
Occupation type
Full-time job in public sector 23.5 13.3 < 0.001
Full-time job in private sector 9.4 34.3
Having own business/ self employed 36.5 32.4
Pension holder 5.9 11.4
Part-time casual worker 5.9 2.9
Student 3.5 2.9
Unemployed 15.3 2.9
Marital status
Single/Unmarried 32.4 20.0 0.138
Married/Cohabiting 65.7 78.8
Divorce/Separated/Widower 1.9 1.2
Education level
Can read only 8.24 6.67 0.733
Primary (5th standard) 14.12 11.43
Secondary (10th standard) 58.82 47.62
College graduate degree 14.12 11.43
Post-graduate degree 4.71 3.81
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levels of depression (Mild, Moderate and Severe) were
slightly high among the individuals with LEA (50.6%)
compared to the control participants (43.8%). The
chi-square test did not indicate a significant difference
for depression level between the two groups. Table 2
also shows the descriptive statistics of BDI scores of the
individuals with LEA and control participants. The mean
values of BDI score of the individuals with LEA and of
the control participants were similar (t = 0.022, df = 188,
p = 0.983). The effect size of the analysis was very triv-
ial (0.003) with the statistical power of 5%. This indi-
cates either a much larger sample size is necessary to
obtain a conclusive association of depression level and
disability due to traumatic amputation, or the effect of
traumatic amputation on mean BDI score is negligible.
Table 3 shows the descriptive statistics of BDI score
of the individuals with LEA separated by presence or
absence of certain health risk factors. Among all the risk
factors, only chronic energy deficiency was associated
with a significantly higher mean value of BDI score.
Participants with hypertension also had a higher mean
value of BDI score, whereas, participants with hyper-
glycemia, hyperlipidemia, hypertriglyceridemia and
overweight reported lower mean value of BDI score than
the participants without those risk factors.
Table 4 shows the results of the two-way analysis of
variance of BDI scores of the individuals with LEA and
controls, considering the presence of disability as a fixed
factor and different physical health traits and economic
condition (ratio between number of rooms in household
and household size) as covariates. This analysis was
done to determine whether depression level were associ-
ated with the health traits controlling for the presence of
a locomotor disability (here LEA). The results reveal that
the physical health traits like BMI and hemoglobin% in
blood had a significant relationship with depression.
Other physical health traits like blood pressure, blood
glucose, cholesterol, and triglycerides did not show any
significant association with depression. The economic
condition had a significant relationship with depression.
There was no interaction between the presence of dis-
ability and any of the physical health traits or the eco-
-nomic condition.
The individuals with LEA belonging to the ‘low’ eco-
Table 2. The levels of depression and the descriptive statistics of BDI scores for the participants with a traumatic amputation and
Levels of BDI Part. with LEA Controls
Depression scores N % N %
Minimal 0-13 42 49.4 59 56.2 Chi-square
Mild 14-19 18 21.2 17 16.2 1.094
Moderate 20-28 13 15.3 15 14.3 df = 3
Severe 29-63 12 14.1 14 13.3 p = 0.779
Total 85 105
Part. with LEA Control t (df = 188)*
N Mean SD N Mean SD 0.022
BDI score 102 15.15 12.36 105 15.19 11.60 p = 0.983
Table 3. Distribution of the individuals with a lower extremity amputation (LEA) separated by presence or absence of certain health
risk factors and the comparisons between the two groups.
Frequency of
individuals with LEA
BDI Scores of individuals
with LEA
Having riskNo riskHaving risk No risk
of BDI scores
(df = 83)
Risk factors Measurements Cut-off points
n% n% Mean ± SD Mean ± SD t p
Systolic Blood Pressure > 140 mm Hg2630.65969.417.92 ± 14.20 13.93 ± 11.38 1.3790.17
Hypertension Diastolic Blood Pres-
sure > 90 mm Hg3945.94654.115.41 ± 12.14 14.93 ± 12.68 0.1760.86
Hyperglycemia Random Blood Glucose > 126 mg/dL3136.55463.514.13 ± 12.44 15.74 ± 12.39 0.5760.57
Hyperlipidemia Total Cholesterol > 200 mg/dL78.2 7891.811.71 ± 5.09 15.46 ± 12.79 0.7660.45
mia Total Triglycerides > 150 mg/dL3945.94654.113.04 ± 10.45 16.80 ± 12.24 1.6550.10
Overweight Body Mass Index > 25 Kg/M2 2630.65969.413.00 ± 10.39 16.10 ± 13.11 1.0670.29
CED Body Mass Index < 18.5 Kg/M21315.37284.722.08 ± 16.94 13.90 ± 11.04 2.2460.03*
SBP = systolic blood pressure, DBP = diastolic blood pressure, CED = chronic energy deficiency, BMI = Body mass index.
* Significant at 5% level.
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Table 4. Two-way analysis of variance of BDI scores using the presence of LEA as a fixed factor and each physical health trait and
economic condition (ratio between number of rooms in the household and household size) as a covariate.
Factor 1 Factor 2
Interaction (fac-
tor 1* factor 2)Corr. Model Intercept Error
Name of the
factor F df p F df p F dfp F dfp F df p dfMean
SBP 0.43 1 0.52 0.45 1 0.510.4610.500.253 0.869.09 1 < 0.01* 186143.72
DBP 1.53 1 0.22 0.61 1 0.440.6310.430.66 30.5812.29 1 < 0.01* 186142.77
Blood glucose 0.76 1 0.39 1.48 1 0.231.97 1 0.160.88 30.4549.81 1 < 0.01* 186142.28
Total cholesterol 1.95 1 0.17 0.29 1 0.590.45 10.510.79 30.5012.34 1 0.01* 186116.60
Triglycerides 1.71 1 0.19 0.87 1 0.350.64 10.420.82 30.4873.79 1 < 0.01* 186140.37
BMI 6.71 1 0.01* 1.24 1 0.720.1110.752.16 30.0929.16 1 < 0.01* 186139.43
Haemoglobin% 5.50 1 0.02* 1.38 1 0.241.42 1 0.242.21 30.0919.02 1 < 0.01* 186139.32
Economic con-
dition 10.91 1 <
0.01* 0.45 1 0.510.44 1 0.513.70 30.01*34.10 1 < 0.01* 186136.17
SBP = systolic blood pressure, DBP = diastolic blood pressure, BMI = Body mass index.
nomic category showed a higher mean value of BDI
score (Table 5). The individuals with LEA in the ‘mid-
dle’ economic group showed a lower mean value of BDI
scores than those in the ‘low’ economic group. The par-
ticipants in the ‘high’ economic group showed the lowest
mean value of BDI scores than the other two groups of
economic condition. Among participants of three eco-
nomic categories a significant difference in BDI scores
was determined (p = 0.023). The mean BDI scores of the
individuals with LEA in different levels of the social
discomfort were significantly different. The individuals
with LEA having ‘extreme’ social discomfort reported a
mean BDI score of 32.67, which was almost two times
higher than the mean BDI scores of the other groups.
The participants experiencing ‘some’ degree of discom-
fort and the participants without any discomfort reported
similar mean BDI scores. A number of participants
(48.4%) had changed their occupation due to coping
with the new situation of locomotor disability. The indi-
viduals (with LEA), who had changed their occupation
after an amputation showed a significantly higher BDI
score than the participants (with LEA) who had not
changed their occupation. Again, the individuals (with
LEA), who perceived problems in conjugal life due to
amputation, showed a significantly higher mean value of
BDI scores than the individuals (with LEA) who re-
ported no problem in their conjugal life.
No significant difference in BDI scores was reported
between the individuals with an above knee amputation
(AKA) and the individuals with a below knee amputa-
tion (BKA) (Table 6). The participants (with LEA), who
were totally independent in their daily activities showed
a lower mean value of BDI score than the participants
who had some kind of dependency. The result of the
t-test showed a marginal difference between the groups
(p = 0.08). The duration of disability did not show a
consistent trend with depression scores. Recently ampu-
tated individuals (up to 2 years) had higher mean values
of BDI score than all other groups. However, the par-
ticipants with a duration of disability between 10 to 20
years showed significantly less depression in comparison
to participants with recent experience of a traumatic
amputation. Other categories showed more or less simi-
lar mean values of BDI scores.
The results of the present study showed that the depres-
sion level of individuals with a traumatic amputation and
control participants were similar. The association of
higher depression were reported with hypertension, and
chronic energy deficiency, whereas, the risk conditions
like hyperglycemia, hyperlipidemia, hypertriglyceride-
mia, and overweight had relationship with a lower de
pression level among individuals with LEA. due to the
dearth of the empirical studies on this area of research
among individuals with LEA the findings of the present
study was not compared to other published data. How-
ever, similar studies of the general (non-amputated)
population showed similar results of association between
depression and hypertension [14,15] and lower choles-
terol level [17-20]. Although few studies of the general
population reported an association between higher de-
pression level and higher blood glucose [16] as well as
obesity [59], the findings of this study did not corrobo-
rate with those findings of earlier studies.
The results of this study also indicated that low eco-
nomic condition had an association with higher depress-
sion in participants with a traumatic amputation, which
was corroborative to the finding of the studies by Ry-
barczyk et al. [5,6]. The association of perceived social
discomfort and high depression levels among the indi-
A. Mozumdar et al. / HEALTH 2 (2010) 878-889
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
Table 5. Descriptive statistics of BDI scores by socioeconomic variables of the individuals with LEA.
Socio-economic variables n (%) BDI score Mean ±
Economic condition No. of room: House hold Size
df (2, 82)
Low N/H < 0.25 29 (34.1) 20.07 ± 14.04 F = 3.932
Middle N/H > 0.25 > 0.5 30 (35.3) 13.57 ± 9.67 p = 0.023
High N/H > 0.5 26 (29.5) 11.50 ± 11.81
Social discomfort Social discomfort scale (SDS) ANOVA
df (2, 82)
Extreme SDS = 9 3 (3.53) 32.67 ± 11.50 F = 3.735
Some SDS = 4 to 8 37 (43.53) 13.19 ± 9.04 p = 0.028
None SDS = 3 45 (52.94) 15.60 ± 13.95
Change of occupation t
(df = 83)
Yes 49 (43.53) 18.38 ± 14.85 t = 2.157
No 53 (56.47) 12.67 ± 9.47 p = 0.034
Perceived problems in the conjugal life due to a disability
(among married participants only)
(df = 65)
Yes 10 (14.93) 26.40 ± 18.06 t = 2.815
No 57 (85.07) 14.32 ± 11.38 p = 0.006
Table 6. Descriptive statistics of BDI scores of the individuals with LEA and its association with disability related factors.
Disability related factors n (%) BDI score
(Mean ± SD) Odds Ratio 95% CI
Levels of amputation t = 0.19
Above knee amputation 27 (31.76) 13.81 ± 13.85 df = 83 Ref. -
Below knee amputation 58 (68.24) 16.78 ± 11.68 p = 0.499 1.01 0.98-1.05
Functional outcome in daily activities (LI = locomotor index) t = 1.795
Totally independent (LI = 42) 59 (69.41) 13.58 ± 11.95 df = 83 Ref. -
Some dependency (LI < 42) 26 (30.59) 18.73 ± 12.77 p = 0.076 1.03 0.996-1.07
Duration of disability
Up to 2 years 4 (4.71) 27.00 ± 15.30 ANOVA Ref. -
More than 2 to 10 years 40 (35.29) 16.23 ± 13.27 F = 1.809 0.95 0.88-1.02
More than 10 to 20 years 32 (31.76) 11.37 ± 9.53 df (4, 80) 0.91 0.84-0.97
More than 20 to 30 years 14 (15.29) 14.62 ± 8.77 p = 0.135 0.94 0.86-1.02
More than 30 years 12 (12.94) 17.82 ± 16.38 0.96 0.88-1.04
viduals with an amputation was also corroborative to the
finding of Rybarczyk et al. [5,6].
The high mean BDI score for the participants who
changed their occupation due to disability indicated the
adverse effect of occupation change on their mental
health. This may be due to the uncertainty in their work-
site or starting a new job. This finding of the present
study corroborates with the study of Whyte and Niven
[4]. A significantly high degree of depression was re-
ported among the participants (with LEA), who per-
ceived problems in their conjugal life due to a disability.
This finding was also corroborative with the earlier
studies [5-7,35].
The results of this study showed a lower depression
level in the individuals with AKA than in the individuals
with BKA and this was corroborative with the findings
of O’Toole et al. [39]. O’Toole et al. [39] explained that
individuals with BKA are less severely disabled in terms
of function and may be in a better position in respect to
their functional abilities, which is more or less similar to
their pre-amputation abilities (except a full-fledged body
image), than those with AKA. As a result, the individuals
with BKA are more sensitive to the differences between
themselves and able-bodied individuals.
A. Mozumdar et al. / HEALTH 2 (2010) 878-889
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
The mean value of the BDI scores in individuals who
had experienced LEA within last 2 years was much
higher although only 4 participants were grouped in that
category. The mean value of BDI score was much less in
the participants who had an amputation 2 to 10 years ago.
Earlier studies like Fisher and Hanspal [60], Furst and
Humphrey [61] had similar findings. The participants
with an experience of traumatic amputation 10 to 20
years ago showed the lowest mean BDI scores. The par-
ticipants who had their amputation 30 years ago showed
a slightly higher mean value of BDI scores than other
categories (i.e. the individuals who had amputated 2-10
years, 10 to 20 years and 20-30 years ago). This result
was consistent with the findings of a few studies [60,62],
however it was in contrast to some studies as well [5,6,
26,38,63]. In an extensive review of studies regarding
depression and time spent since amputation, Horgan and
MacLachlan [44] commented that the findings of a
higher depression level in some earlier studies might be
due to the use of CES-D scales for diagnosing depres-
sion, which usually overestimate depression in their
study sample [64]. In explaining such associations of
depression and time since amputation it can be theorized
that there are three phases in adapting to change in body
image, social discomfort and functional difficulties. The
initial ‘shock’ is associated with a high level of depres-
sion, followed by ‘adapting with the situation’ (the
learning and adaptation phase of a new life with amputa-
tion). When the time since amputation is long ago, the
health deterioration with the advancing age and increas-
ing difficulties due to physical immobility causes an
increase in depression level.
The inherent errors and limitations of the cross sec-
tional data of the present study cannot be ruled out. The
result of the present study should not be considered as
any definitive finding in understanding depression and
its bio-social correlates among individuals with LEA,
but showed some trends which can not be ignored alto-
gether. A possible and significant limitation for this
finding is the 90% non-response rate in the sample. The
level of depression may have influenced whether an in-
dividual responded to the survey or not. Individuals with
higher levels of depression may have been too depressed
to agree to participate in the study. Conversely, individu-
als who were depressed may have been more likely to
respond so as to have the opportunity to discuss their
feelings. However, due to a lack of maintenance of
medical records it was difficult to control such con-
founding factors for the present study. It is also worthy
to mention that all the individuals with LEA had pros-
thesis and therefore, they were to some extent rehabili-
tated. This may help to reduce the depression level
among the individuals with LEA. Possibly, because of
these conditions, the post hoc power analysis revealed a
trivial effect size for the difference in depression level
between the individuals with a traumatic amputation and
controls, suggesting a larger sample size is necessary to
reveal a meaningful clinical result. Since the effect of
rehabilitation on the depression and bio-social correlates
can not be ruled out, it would have been better to repeat
the study on non-rehabilitated individuals with LEA as
well, to understand the effect of rehabilitation on mental
health of the individuals with LEA. The levels of reha-
bilitation, facilities and benefits available to individuals
with LEA in developed countries are not comparable
with developing countries like India. In view of these
circumstances, although the present study showed some
corroborative and contrasting findings to the other stud-
ies from the western population, how far the other stud-
ies were comparable was under question. Still, the com-
parisons of the findings were done due to the lack of
similar studies on the Indian population. The present
study acknowledges these limitations but it is still rele-
vant under limited resources, infrastructure, and con-
The results of the present study indicate how the indi-
viduals with a traumatic LEA in Kolkata were finding
themselves in the crossroads of changing societal atti-
tude and its effects on their mental health. The individu-
als with LEA did not show any effect of being amputated
or physically impaired on their depression level. But the
individuals with LEA were showing higher level of de-
pression when they were experiencing social problems
such as ‘social discomfort’, forced to change their occu-
pations, facing trouble in their conjugal life or facing
dependency in their daily activities. At the same time, it
was also evident that the societal attitude towards people
with a disability was still need to be changed, so that the
individuals with a disability could get jobs in private
sectors with equal proportions as general people. If that
change happens in future, the dependency on job reser-
vation in the public sector would be no longer necessary
at all. The primary concern for most of the study par-
ticipants was to earn for the basic need of life (food,
dress and shelter) rather than maintaining a good health.
It may be the reason that the sample population of the
present study showed a positive relation of depression
level with CED rather with overweight or high blood
glucose level. To the participants, being overweight
(body) was not a matter of illness but a symbol of abun-
dance. The association of depression with other social
correlates like change of occupation, and problems in
conjugal life may also be because of economic instabil-
ity of the study population. In developing countries like
India, the physical, social and psychological well-being
is incapacitated until and unless economic security is
A. Mozumdar et al. / HEALTH 2 (2010) 878-889
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/
Openly accessible at
We expected that the individuals with LEA will be at a
higher level of depression than the general population,
but the findings of this study did not show any such dif-
ference. The depression level of the individuals with
LEA also was not associated to most of the physical
health factor. Whereas, presence of chronic energy defi-
ciency and socio-economic problems were significantly
associated to a higher level of depression among indi-
viduals with LEA. That is why; the wellbeing of the in-
dividuals with LEA can only be achieved by improving
the economic condition with a positive societal attitude
towards disability.
The authors are grateful to the study participants for their kind help and
cooperation. Financial and logistic support was given to this study by
the Indian Statistical Institute, Kolkata. We thank Katie Gunter at Cen-
ter for Writers, North Dakota State University for reviewing the manu-
script. Both the authors participated in study design, data analysis and
writing the manuscript. AM collected the field data for the present
study. No author had any financial or personal conflict of interest in the
organization supporting the research.
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