## 4 Discussion  
In the current study, the incidence of depression increased in association with the treatment period among patients with diabetic foot. Limb-saving treatment was associated with a higher depression rate than amputation. With regard to risk factors contributing to the risk of depression development, sex, number of comorbid diseases, and chronic limb-saving procedure were found to be significant factors. Nonsurgical limb-saving treatment for diabetic foot ulcers involves interventions for local pathologic factors, including debridement, pressure relief, antibiotic treatment for infection, and revascularization. Such procedures, while providing the benefits of limb-saving and mobility maintenance, are time-consuming, leading patients to worry about their future [3]. [PERSON] et al. [23] reported higher depression scores in association with \begin{table}
\begin{tabular}{c c c c c} \hline \hline
**Variables** & **HR** & \multicolumn{3}{c}{**95\% CI**} \\  & **Lower** & **Upper** & \(p\)**-Value** \\ \hline Sex & & & & \\ Male & Reference & & & \\ Female & 1.275 & 1.117 & 1.451 & \textless{}0.001 \\ Age & 1.004 & 1.000 & 1.009 & 0.055 \\ CCI & 1.125 & 1.098 & 1.151 & \textless{}0.001 \\ Treatment & & & & \\ method & & & & \\ Limb-saving & 2.805 & 2.478 & 3.183 & \textless{}0.001 \\ Amputation & & & & \\ type & & & & \\ Minor & 1.036 & 1.000 & 1.077 & 0.69 \\ Major & Reference & & & \\ \hline \hline \end{tabular} HR = hazard ratio, CI =<Confidence interval, CCI = Charlson comorbidity index.  
\end{table} 
Table 2: [PERSON] regression analysis. Figure 2: Comparison of the incidence of depression between the limb-saving group and amputation groups. Time (years) is defined as the duration from the initiation of the diabetic foot treatment. delayed diabetic foot ulcer healing. Another study reported progression in the degree of mood impairment in patients among whom the ulcers failed to heal despite lengthy treatment periods [24]. Conversely, amputation, which may have a positive effect in shortening a patient's treatment period, may have a preventive effect on his/her mood compared to a limb-saving procedure, as it provides a definite result. A previous study reported that minor amputation does not negatively affect patients' health-related quality of life, compared to conservative treatment in patients with diabetic foot ulcers [25]. Therefore, in terms of depression, surgeons' efforts that are driven towards retaining patients' body parts may not positively influence their mental well-being, owing to treatment period prolongations and uncertainties. In this study, women with diabetic foot were more susceptible to depression than men, which is consistent with the results of previous studies [8; 26]. [PERSON] et al. [8] indicated that women are more aware of their body parts, and therefore tend to utilize health services more often than men. In addition, women tend to be the caregivers for both themselves and their family members in cases of chronic diseases [27]. They are also more subject to sex-specific conditions, such as pregnancy, menstrual cycle changes, and postpartum stress [26]. These factors may have a strong effect on a woman's feeling of endangerment in terms of the complications associated with foot ulcer. Although the current study did not identify an association between depression and age, most previous studies reported that patients with depression tend to be younger [18; 28]. From the socioeconomic point of view, younger people who tend to be the breadwinners for themselves and their family may perceive chronic foot ulcer in a more serious light than do older people. Additionally, owing to the widespread individualism in modern society, characterized by restricted lives and a lack of social support, younger diabetic foot ulcer patients are more susceptible to the development of a depressed mood [16]. In line with other studies, we found that depression among diabetes patients was directly related to the coexistence of other chronic diseases [17; 29].