lower limb amputation is carried out for a variety of reasons including peripheral vascular disease , diabetes , trauma , tumor , or secondary infections . no studies on the incidence or the prevalence of amputation in jordan are available , but al - woricat ( 1996 ) assessed the epidemiology of amputees in the royal medical services in jordan . he evaluated 865 amputees over 7.5 years and reported that the trans - tibial was the most common level of amputation ( 51.2% ) , followed by trans - femoral ( 17.57% ) ; male to female ratio was 3.5:1 , and trauma was the leading cause of amputation ( 50.17% ) , followed by diabetes mellitus ( 29% ) . most patients who lose a limb as a result of traumatic or surgical procedures encounter a series of complex psychological responses ( cansever et al 2003 ) . many people successfully use these responses to adjust to amputation , but others develop psychiatric symptoms ( frank et al 1984 ) . shula and colleagues ( 1982 ) and frierson and lippmann ( 1987 ) note that as many as 50% of all amputees require some sort of psychological intervention , and shula and colleagues ( 1982 ) reported that depression is the most common psychological reaction among amputees . according to research by kindon and pearce ( 1982 ) , kohl ( 1984 ) , and cansever and colleagues ( 2003 ) , psychological reactions to amputation depend on a number of factors , which include age and sex , type and level of amputation , lifelong patterns of coping with stress , value placed on the lost limb , and expectations from the rehabilitation program . kohl ( 1984 ) added that the individuals affected by the traumatic loss of a limb are required to face a redefined body and self as well as a new reality . horgan and maclachlan ( 2004 ) concluded that factors associated with positive adjustment to limb loss include greater time since amputation , more social support , greater satisfaction with the prosthesis , active coping attempts , an optimistic personality , a lower level of amputation in the case of lower limbs , and lower levels of phantom limb pain and stump pain . national data on the prevalence of depression and anxiety among lower limb amputees in jordan are not readily available . the aim of this study was to assess the prevalence of anxiety and depression in jordanian patients with lower limb amputation with different clinical and sociodemographic data ( gender , marital status , social support , income , type and level of amputation , and occupation ) . this study included 56 lower limb amputees ( 83.9% [ n = 47 ] males , 16.1% [ n = 9 ] females , 1873 years in age [ mean 45  18 ] ( tables 1 and 2 ) who were inpatients and outpatients recruited from jordan university hospital , royal rehabilitation center at the king hussain medical center , and al - basheer hospital in amman , jordan from january 2007 to june 2007 . we were unable to contact 25 patients to obtain their complete data , 6 patients did not consent to participate , and 5 patients were excluded because they did not respond to part(s ) of the questionnaire . patient sociodemographic and clinical data patient sociodemographic and clinical data according to their anxiety and depression levels abbreviations :  male ,  female , s. single , m. married , + ve there was family support ,  ve there was no family support , t. traumatic , d. disease , ak . above knee , all study patients had amputation of one lower limb , 22 above the knee and 34 below the knee . thirty - three amputations were due to peripheral vascular disease and/or diabetes mellitus , and 2 due to malignancy . of the 21 trauma amputees , 8 were due to road traffic accidents , 2 to mine explosions , and 1 to gun shot injury ( table 1 and 2 ) . a prosthesis was fitted , on average , 6 months after amputation ; 32 patients had a modular prosthesis , 16 a conventional prosthesis , and 8 had no prosthesis . patients known to have congenital amputations , bilateral lower limb amputation , syme s amputation , partial foot amputation , open amputation , upper limb amputation , cognitive deficits , previous history of psychiatric disorders before having amputation , or those known to use drugs that may cause anxiety or depression were excluded from the study . the participants were fully informed about the nature of the study procedure and consent was obtained from each subject before participating in the study . during a face to face interview participants were asked to respond to a questionnaire that included a battery of questions requesting brief sociodemographic information ( age , sex , marital status , income , social support , use of prosthesis , and occupation ) and clinical data ( anxiety and depression scores , characteristics of amputation , duration since amputation , and complications related to amputation and use of prosthesis ) . social support was evaluated using a single item measure of social support , which read  how many people do you have near you that you can readily count on for help in times of difficulty ?  . responses of 0 or 1 indicate negative social support ; 25 or more indicate positive social support ( blake and mckay 1984 ) . income was reported in jordanian dinars ( jd ) per month , 1 jd = us$1.4 . the levels of depression and anxiety symptoms after lower limb amputation were assessed using a simple screening test , the hospital anxiety and depression scale ( hads ) , which has good sensitivity and specificity when used for formal psychiatric assessment and diagnosis ( zigmond and snaith 1983 ) . hads is a validated scale for screening for symptoms of anxiety and depression and avoids confounding emotional symptoms with those of physical illness ( snaith and taylor 1985 ) . each question was answered on a four point ( 03 ) response category so the possible scores ranged from 021 for both anxiety and for depression . a score of 8 and above in either subscale was considered to be a case of psychological disturbance while scores of 07 were considered normal ( zigmond and snaith 1983 ) . depression  was assessed according to questions such as :  do you take as much interest in things as you used to do ? do you feel cheerful ?   do you feel optimistic about the future ?  . anxiety  level was assessed by questions such as :  do you feel tense or wound up ?   do you worry a lot ? data were analyzed using spss ( version 9.1 ; spss inc , chicago , il ) . the collected data were statistically treated to show the mean , range , standard deviation , and standard error of mean for all sets of continuous variables such as age , income , and time since amputation . frequency distribution was done also for all categorized variables such as gender , occupation , family support , and type of amputation . independent t - test was conducted to compare anxiety and depression scores among patients with opposing sociodemographic data this study included 56 lower limb amputees ( 83.9% [ n = 47 ] males , 16.1% [ n = 9 ] females , 1873 years in age [ mean 45  18 ] ( tables 1 and 2 ) who were inpatients and outpatients recruited from jordan university hospital , royal rehabilitation center at the king hussain medical center , and al - basheer hospital in amman , jordan from january 2007 to june 2007 . we were unable to contact 25 patients to obtain their complete data , 6 patients did not consent to participate , and 5 patients were excluded because they did not respond to part(s ) of the questionnaire . patient sociodemographic and clinical data patient sociodemographic and clinical data according to their anxiety and depression levels abbreviations :  male ,  female , s. single , m. married , + ve there was family support ,  ve there was no family support , t. traumatic , d. disease , ak . above knee , all study patients had amputation of one lower limb , 22 above the knee and 34 below the knee . thirty - three amputations were due to peripheral vascular disease and/or diabetes mellitus , and 2 due to malignancy . of the 21 trauma amputees , 8 were due to road traffic accidents , 2 to mine explosions , and 1 to gun shot injury ( table 1 and 2 ) . a prosthesis was fitted , on average , 6 months after amputation ; 32 patients had a modular prosthesis , 16 a conventional prosthesis , and 8 had no prosthesis . patients known to have congenital amputations , bilateral lower limb amputation , syme s amputation , partial foot amputation , open amputation , upper limb amputation , cognitive deficits , previous history of psychiatric disorders before having amputation , or those known to use drugs that may cause anxiety or depression were excluded from the study . the participants were fully informed about the nature of the study procedure and consent was obtained from each subject before participating in the study . during a face to face interview participants were asked to respond to a questionnaire that included a battery of questions requesting brief sociodemographic information ( age , sex , marital status , income , social support , use of prosthesis , and occupation ) and clinical data ( anxiety and depression scores , characteristics of amputation , duration since amputation , and complications related to amputation and use of prosthesis ) . social support was evaluated using a single item measure of social support , which read  how many people do you have near you that you can readily count on for help in times of difficulty ?  . response options were  0  ,  1  ,  25  ,  69  , or  10 or more  . responses of 0 or 1 indicate negative social support ; 25 or more indicate positive social support ( blake and mckay 1984 ) . income was reported in jordanian dinars ( jd ) per month , 1 jd = us$1.4 . the levels of depression and anxiety symptoms after lower limb amputation were assessed using a simple screening test , the hospital anxiety and depression scale ( hads ) , which has good sensitivity and specificity when used for formal psychiatric assessment and diagnosis ( zigmond and snaith 1983 ) . hads is a validated scale for screening for symptoms of anxiety and depression and avoids confounding emotional symptoms with those of physical illness ( snaith and taylor 1985 ) . each question was answered on a four point ( 03 ) response category so the possible scores ranged from 021 for both anxiety and for depression . a score of 8 and above in either subscale was considered to be a case of psychological disturbance while scores of 07 were considered normal ( zigmond and snaith 1983 ) . depression  was assessed according to questions such as :  do you take as much interest in things as you used to do ? do you feel cheerful ?   do you feel optimistic about the future ?  . anxiety  level was assessed by questions such as :  do you feel tense or wound up ?   do you worry a lot ? data were analyzed using spss ( version 9.1 ; spss inc , chicago , il ) . the collected data were statistically treated to show the mean , range , standard deviation , and standard error of mean for all sets of continuous variables such as age , income , and time since amputation . frequency distribution was done also for all categorized variables such as gender , occupation , family support , and type of amputation . independent t - test was conducted to compare anxiety and depression scores among patients with opposing sociodemographic data of the 56 patients , seventy - five percent ( n = 42 ) were single and 25% ( n = 14 ) were married ; 80% ( n = 45 ) had no work and 20% ( n = 11 ) had work ; 55% ( n = 31 ) received no social support and 45% ( n = 25 ) received good social support . based on hads our results showed that among the 56 amputees , 63% ( n = 35 ) were normal ( anxiety score 2  2.4 , income 162  68 jd , and amputation duration 128  73 months ) while 37.5% ( n = 21 ) were abnormal ( anxiety score 10.9  3.1 , income 122  56 jd , and amputation duration 56  28 months ) ( table 1 ) . comparing different anxiety scores revealed a significant decrease in the score between patients who received social support ( mean = 3.3  4.0 ) compared to those without support ( mean = 7.1  5.2 ) , patients with amputation due to disease ( mean = 4.0  4.4 ) compared to those due to trauma ( mean = 7.7  5.3 ) , and in patients with above knee amputation ( mean = 3.4  4.5 ) compared to those with below knee amputation ( mean = 6.7  5.0 ) with p values equal ( 0.004 , 0.006 , and 0.01 respectively ) . however , no significant difference was found between males versus females , single versus married , and employed versus unemployed with p values equal ( 0.15 , 0.77 , and 0.25 respectively ) ( table 2 ) . forty - four percent ( n = 4 ) of females had anxiety compared with 36% ( n = 17 ) of males . also , 36% ( n = 5 ) of married individuals had anxiety compared with 38% ( n = 16 ) of singles . we recorded that 82% ( n = 9 ) of individuals who had work were normal compared with 58% ( n = 26 ) of individuals who had no work . individuals who received no social support were anxious more frequently , that is , 48% ( n = 15 ) , than those who received social support 24% ( n = 6 ) . fifty - seven percent ( n = 12 ) of amputated cases as a result of trauma showed anxiety and only 26% ( n = 9 ) of amputated cases as a result of disease showed anxiety . fifty three percent ( n = 18 ) of cases with below knee amputation had anxiety compared with 14 % ( n = 3 ) in cases with above knee amputation ( table 2 and figure 1 ) . data of the 56 amputees showed that 80% ( n = 45 ) were normal ( depression score 2.2  1.9 , income 157  68 jd , and amputation duration 115  70 months ) while 20% ( n = 11 ) were abnormal ( depression score of 10.9  3.8 , income 105  36 jd , and amputation duration 45  29 months ) ( table 1 ) . comparing depression scores showed a significant decrease in the score of patients who received social support ( mean = 2.4  3.7 ) compared with those without support ( mean = 5.1  4.3 ) , and in patients with amputation due to disease ( mean = 2.6  3.2 ) compared with those with amputation due to trauma ( mean = 6.0  4.9 ) with p values equal ( 0.01 and 0.002 respectively ) . on the other hand no significant difference was found between males versus females , single versus married , employed versus unemployed , and above knee versus below knee with p values equal ( 0.85 , 0.21 , 0.12 , and 0.11 respectively ) ( table 2 ) . it is important to mention that the eleven cases who showed depression , according to the hads , had no work . ten of them were single , received no social support , and their amputations were the result of trauma . furthermore , nine of them were males and had below knee amputation ( table 2 and figure 2 ) . of the 56 patients , seventy - five percent ( n = 42 ) were single and 25% ( n = 14 ) were married ; 80% ( n = 45 ) had no work and 20% ( n = 11 ) had work ; 55% ( n = 31 ) received no social support and 45% ( n = 25 ) received good social support . based on hads our results showed that among the 56 amputees , 63% ( n = 35 ) were normal ( anxiety score 2  2.4 , income 162  68 jd , and amputation duration 128  73 months ) while 37.5% ( n = 21 ) were abnormal ( anxiety score 10.9  3.1 , income 122  56 jd , and amputation duration 56  28 months ) ( table 1 ) . comparing different anxiety scores revealed a significant decrease in the score between patients who received social support ( mean = 3.3  4.0 ) compared to those without support ( mean = 7.1  5.2 ) , patients with amputation due to disease ( mean = 4.0  4.4 ) compared to those due to trauma ( mean = 7.7  5.3 ) , and in patients with above knee amputation ( mean = 3.4  4.5 ) compared to those with below knee amputation ( mean = 6.7  5.0 ) with p values equal ( 0.004 , 0.006 , and 0.01 respectively ) . however , no significant difference was found between males versus females , single versus married , and employed versus unemployed with p values equal ( 0.15 , 0.77 , and 0.25 respectively ) ( table 2 ) . forty - four percent ( n = 4 ) of females had anxiety compared with 36% ( n = 17 ) of males . also , 36% ( n = 5 ) of married individuals had anxiety compared with 38% ( n = 16 ) of singles . we recorded that 82% ( n = 9 ) of individuals who had work were normal compared with 58% ( n = 26 ) of individuals who had no work . individuals who received no social support were anxious more frequently , that is , 48% ( n = 15 ) , than those who received social support 24% ( n = 6 ) . fifty - seven percent ( n = 12 ) of amputated cases as a result of trauma showed anxiety and only 26% ( n = 9 ) of amputated cases as a result of disease showed anxiety . fifty three percent ( n = 18 ) of cases with below knee amputation had anxiety compared with 14 % ( n = 3 ) in cases with above knee amputation ( table 2 and figure 1 ) . data of the 56 amputees showed that 80% ( n = 45 ) were normal ( depression score 2.2  1.9 , income 157  68 jd , and amputation duration 115  70 months ) while 20% ( n = 11 ) were abnormal ( depression score of 10.9  3.8 , income 105  36 jd , and amputation duration 45  29 months ) ( table 1 ) . comparing depression scores showed a significant decrease in the score of patients who received social support ( mean = 2.4  3.7 ) compared with those without support ( mean = 5.1  4.3 ) , and in patients with amputation due to disease ( mean = 2.6  3.2 ) compared with those with amputation due to trauma ( mean = 6.0  4.9 ) with p values equal ( 0.01 and 0.002 respectively ) . on the other hand no significant difference was found between males versus females , single versus married , employed versus unemployed , and above knee versus below knee with p values equal ( 0.85 , 0.21 , 0.12 , and 0.11 respectively ) ( table 2 ) . it is important to mention that the eleven cases who showed depression , according to the hads , had no work . ten of them were single , received no social support , and their amputations were the result of trauma . furthermore , nine of them were males and had below knee amputation ( table 2 and figure 2 ) . many studies have investigated the prevalence of depression and anxiety among individuals with lower limb amputations . in our study , prevalence of depressive and anxiety symptoms were 20% and 37% respectively , which is consistent with several previous studies that confirmed high rates of anxiety and depressive symptoms after amputation with prevalence up to 41% ( kashani et al 1983 ; schubert et al 1992 ; hill et al 1995 ; cansever et al 2003 ; atherton and robertson 2006 ; seidel et al 2006 ) . several studies have reported no relationship between time since amputation and depressive symptoms ( rybarczyk et al 1992 ; thompson et al 1984 ) or psychiatric symptoms ( horgan and maclachlan 2004 ) . however , our data revealed that the longer the time since amputation , the lesser is the prevalence of psychological abnormalities which is evident for either anxiety or depression , which could be attributed to psychological adjustments that follow amputation . in their review of psychological adjustments to amputation horgan and maclachlan ( 2004 ) concluded that although depression and anxiety appear to be relatively high up to 2 years post amputation , they decline thereafter to levels comparable to those in the general population . a recent study showed rapid resolution of depressive and anxiety symptoms in individuals with lower limb amputation after a period of inpatient rehabilitation ( average period 54.3 days ) ( singh and hunter 2007 ) . gender is one sociodemographic factor that could be associated with outcome following amputation . in terms of psychological well - being following amputation , most studies have found no difference in psychosocial outcome between men and women ( bradway et al 1984 ; williamson 1995 ; williamson and walters 1996 ) . the data from our study revealed that females suffered from more reactive depression and anxiety symptoms than males . this result is similar to those of previous studies performed by kashani and colleagues ( 1983 ) , otoole and colleagues ( 1984 ) , and pezzin and colleagues ( 2000 ) , which have reported that women are more likely to experience depression , and to perform more poorly on a measure that includes an assessment of emotional adaptability . in terms of the cause of amputation , in both subscales , our results showed that traumatic amputees had higher levels of depression and anxiety compared with those who had their amputation because of disease . in accordance with our results , fisher and hanspal ( 1998 ) and livneh and colleagues ( 1999 ) suggested that young adults with traumatic amputation may be at higher risk of major depression compared with individuals with disease - related amputations . other studies examining the relationship between cause of amputation and psychosocial outcome have found no effect of amputation on psychiatric symptoms ( shukla et al 1982 ) , anxiety ( weinstein 1985 ) , and depressive symptoms ( kashani et al 1983 ; rybarczyk et al 1992 ; williamson and walters 1996 ) . according to engstorm and colleagues ( 2001 ) our results showed that single patients and patients with no social support had experienced more depression and anxiety . williamson and colleagues ( 1984 ) , thompson and haran ( 1984 ) , rybarczyk and colleagues ( 1992 ) , and rybarczyk and colleagues ( 1995 ) , found that increased social isolation and lower levels of perceived social support are associated with higher levels of depressive symptomatology . particularly helpful in the adjustment of the adult amputee is the presence of a supportive partner who assumes a flexible approach , takes over functions when needed , but at all times maintains the amputee s self - esteem ( kohl 1984 ; parkes 1976 ) . the results of the current study showed that bk amputees had higher levels of depression compared with ak amputees . according to weinstein ( 1985 ) , despite the fact that above knee ak amputations are associated with poorer rehabilitation outcomes and higher levels of activity restriction , ak amputations have not been found to be associated with increased levels of anxiety , social discomfort , general psychiatric symptoms ( shukla et al 1982 ) , depression ( behel et al 2002 ) , or adjustment to amputation ( tyc 1992 ) . most notably , otoole et al ( 1984 ) found that the relationship between amputation level and psychological outcome showed that individuals with below knee ( bk ) amputation were more likely to be depressed than those with ak amputations . it was suggested that because individuals with bk amputations are less severely disabled in terms of functioning than those with ak amputations , they may be in a better position to compare their functional abilities with their premorbid abilities and , as a result , be more sensitive to the differences between themselves and able - bodied individuals ( otoole et al 1984 ) . in terms of the vocational factor , current amputees of this study reacted with more depression and anxiety symptoms if they were unemployed or had a low income . these results are supported by seymour ( 2002 ) , who reported that patients with a disability , who can not do their former jobs and who face a loss of income will have more adjustment problems . according to engstorm and colleagues ( 2001 ) , employment prospects have a powerful affect on individuals , both at the level of their sense of identity and their social and financial situation . the current study had certain limitations : 1 ) the small sample , 2 ) the wide variety in age , 3 ) and the study was descriptive , therefore the subjects were not followed longitudinally . many subjects with surgical amputations have associated illnesses such as diabetes mellitus which may contribute to their symptoms . future studies investigating other demographic / social factors can expand the role of depression and anxiety after lower limb amputation ( eg , sexuality , phantom pain , type and fitting of prosthesis ) . thus we recommend adequate psychiatric evaluation , follow up , and rehabilitation for all individuals with lower limb amputation , and especially for those with a high propensity for these disorders . preoperative preparation , early prosthetic fitting and mobilization , vocational rehabilitation and psychotherapy may be adequate approaches to decrease the impact of disability and improve functional outcomes and quality of life in this population , and should be a concern for all health professionals involved in the care of amputees . extensive rehabilitation with the use of an interdisciplinary team approach is one of the most successful ways to return the amputee to the work place . a combination of occupational therapy , physical therapy , vocational rehabilitation , and psychological support generally promote a sense of well being and return the amputee to a level of independence .
objectivethis study aimed to assess the prevalence of anxiety and depression among jordanian lower limb amputees with different clinical characteristics and sociodemographic data ( gender , marital status , social support , income , type and level of amputation , and occupation).methodsparticipants were 56 patients with unilateral lower limb amputation with mean duration ( 8.4  5.75 years ) . 
 they were recruited from inpatient and outpatient clinics of jordan university hospital , royal farah rehabilitation center , and al - basheer hospital in amman , jordan . 
 participants responded to a questionnaire that included a battery of questions requesting brief information about sociodemographic variables and characteristics of amputation . 
 the level of depression and anxiety in each participating patient was assessed by the hospital anxiety and depression scale ( hads).resultsthe prevalence of anxiety and depressive symptoms were 37% and 20% , respectively . 
 factors associated with high prevalence of psychological symptoms included female gender , lack of social support , unemployment , traumatic amputation , shorter time since amputation , and amputation below the knee . 
 these findings were confirmed by a significant reduction of anxiety and depression scores in patients who received social support , patients with amputation due to disease , and patients with amputation above the knee . 
 presence of pain and use of prosthesis had no effect on the prevalence.conclusionsthe findings of the present study highlight the high incidence of psychiatric disability and depression in amputees ; it also showed the importance of sociodemographic factors in psychological adjustment to amputation . 
 it is suggested that psychiatric evaluation and adequate rehabilitation should form a part of their overall management .