Dr. Rohan Jain, J17093, Dr. Rakesh Shakya, Dr. DhananjayGiri
Author – Dr. Rohan Jain, SNC Chitrakoot
AIM: To determine the prevalence and risk factors for anxiety and depression among glaucoma patients and assess their relationship with quality of life (QOL).
Cross-sectional study including 50 glaucoma patients. Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Visual Function Questionnaire (VFQ25) were evaluated for depression, anxiety and impact on QOL.
Frequency of depression and anxiety were 50% and 42% respectively. Mean HAM-D score 8.58±4.84, HAM-A score 6.46±3.89, VFQ25 score 66.58±7.78.Risk factors for depression: female sex (P=0.037), higher cup-disc ratio (P=0.028), lower mean VFQ25 score (P<0.002) and angle closure glaucoma (P=0.019). Risk factors for anxiety: lower mean VFQ25 score (P=0.005).
Glaucoma patients have relatively high prevalence of depression and anxiety, so a multidisciplinary approach involving ophthalmology and psychiatry may be required.
Glaucoma is a chronic debilitating disease. In 2010, approximately 8.4 million people were affected worldwide. 1
Glaucoma often have high prevalence of coexisting psychiatric disorders such as anxiety2-5 and depression2,3,6-8 as reported in previous studies. They may arise in glaucoma patients due to the fear of potential blindness, heavy economic burden caused by multiple medications and surgeries, and also impairments in daily activities such as driving9 and reading.10
Measurement of the quality of life of patients with glaucoma can be complex because of decreased quality of life due to: damage to the visual field, the psychological effect of the diagnosis and the side effects and cost of treatment 11. Also affected by co morbidity of other chronic diseases and the socio-economic level of patients .12,13
The aim of this study is to determine the prevalence and risk factors for anxiety disorder and depression among glaucoma patients in Central India and to assess the relationship between QOL and depression/anxiety for understanding their functional and psychosocial burden.
MATERIALS AND METHODS
In this cross-sectional study, glaucoma patients were consecutively recruited from a tertiary care hospital, from February 2016 to May 2016. Informed consent was taken from all participants before enrollment. Study was approved by the local institutional review board . Glaucoma was diagnosed by an ophthalmologist based on glaucomatous disc cupping and characteristic visual field defects with or without increased intraocular pressure (IOP).
Inclusion criteria :
1) Age – 21 years and above; 2) with a known clinical diagnosis of primary open-angle glaucoma (POAG) or primary angle-closure glaucoma (PACG) or normal tension glaucoma (NTG) .
Exclusion criteria :
1) Patients with secondary glaucoma or coexisting ocular disease (eg, cataract, diabetic retinopathy, age related macular degeneration). 2) Individuals with coexisting physical and psychiatric disorders (ie, depression/anxiety), or any form of medication that possibly lead to psychiatric disorders or cognitive impairment (such as digoxin and steroids), except those on topical β-blockers and prostaglandin analogues.
A comprehensive ophthalmic examination was carried out by a glaucoma fellowship-trained clinician on all participants, which included best-corrected visual acuity (BCVA), IOP, gonioscopy, standard automated perimetry (Humphrey visual field), and optic disc evaluation. Sociodemographic information and treatment histories were also collected through personal interviews and chart review.
Evaluation of Depression and Generalized Anxiety Disorder
The Hamilton Depression Rating Scale (HAM-D)15 and the Hamilton Anxiety Rating Scale (HAM-A)16 were used to evaluate for depression and anxiety disorder, respectively. Both questionnaires are clinician-rated scales that were easy to administer with high validation and reliability scores.
For the 17-item HAM-D, total scores can range from 0 to 54. Scores between 0 and 6 indicate that depression is absent, scores between 7 and 17 indicate mild depression, scores between 18 and 24 indicate moderate depression, and scores over 24 indicate severe depression.
The HAM-A consists of 14 items, each measuring specific symptoms of anxiety (eg, tension, insomnia, dyspnea), which are rated by the interviewer on a scale from 0 (not present) to 4 (very severe/incapacitating). Total scores may range from 0 to 56, where <17 indicates mild severity, 18 to 24 mild to moderate severity, and 25 to 30 moderate to severe.
Evaluation of QOL
The National Eye Institute Visual Function Questionnaire (VFQ25) was administered to assess the impact of the subject’s affected visual function. The VFQ25 was developed by RAND and funded by the NEI. It contains 12 subscales that assess the impact of ocular disease on general health, general vision, near activities, distance activities, driving, peripheral vision, color vision, ocular pain, and vision-related role difficulty, dependency, social function, and mental health. The total score on each subscale can range from 0 to 100, with 100 indicating no disability.
All 3 questionnaires (HAM-A, HAM-D, and VFQ25) were administered in English. The questionnaires were administered through face-to-face interviews. Before this, interviewer training was conducted to standardize the administration of the questionnaires. Interviewers had to adhere strictly to the questionnaire with no rephrasing allowed.
Data analysis was carried out using SPSS Statistics (Version 17.0). Continuous variables were compared using the Mann-Whitney test, whereas categorical variables were compared using the Pearson Chi- square test. Univariate logistic regression was performed to determine the influence of risk factors on depression and anxiety. A P-value of <0.05 was considered to indicate statistical significance.
A total of 50 patients with the mean age of 55.4 ± 11.5 years (range, 32 to 80 y). Majority of our patients were male with M : F ratio being 1.27 : 1.
There were 17 patients diagnosed with POAG , 18 with PACG and 15 with Normal Tension Glaucoma. Most had bilateral disease (98%), with a mean IOP of 22.78 ± 5.88 mm Hg (range, 10-50 mm Hg), and mean cup-disc ratio of 0.77 ± 0.17 (range, 0.45 -1). The mean number of glaucoma surgeries performed was 1.01 ± 0.77 (range, 0 to 3), the most common being trabeculectomy (22 %). The mean number of eyedrops used was 1.92 ± 0.88 (range, 0 to 4), and the most common eyedrops used were β-blockers (64%), prostaglandin analogues (49%).
Prevalence of Depression and Anxiety Disorder
Among the participants in our study, 50% and 42% had depression and anxiety disorder, respectively. The mean HAM-D score was 8.58 ± 4.84 ( range, 1-19), whereas the mean HAM-A score was 6.46 ± 3.89 (range, 1-21).
The mean VFQ25 score was 66.58 ± 7.78 (range, 52 to 84).
Risk Factors Associated With Depression and Anxiety
Comparisons were done separately for participants with and without depression, and for participants with and without anxiety disorder. Continuous variables, such as age, visual acuity and QOL scores, were compared using the Mann-Whitney test. Categorical variables, such as glaucoma type were compared using the Pearson Chi- square test.
The analysis revealed that depression was significantly associated with sex , higher cup-disc ratio (CDR), average QOL scores (P<0.001), angle closure glaucoma and all VFQ25 subscale scores. Anxiety disorder was significantly associated average QOL score and all VFQ25 subscale scores except social functioning and driving scores.
To confirm the association between depression/anxiety disorder and these identified risk factors, univariate logistic regression analysis was performed. The analysis revealed that patients with glaucoma are more likely to suffer from depression if: (1) they are female (P=0.037); (2) they have a higher logMAR BCVA in the worse eye (P=0.008); (3) a higher CDR (P=0.028) is found on examination; (4) they have a lower mean VFQ25 score (P<0.002); (5) patients having PACG (P= 0.019) . Patients with glaucoma are more likely to suffer from anxiety disorder if they have a lower mean VFQ25 score (P<0.005).
The prevalence of depression and generalized anxiety disorder among patients with glaucoma in our study was 50% and 42%, respectively.
Type of Glaucoma and Depression/Anxiety Disorder
In our study, we find a significant difference in the prevalence of depression between POAG and PACG. Our study concluded that the levels of anxiety and depression were significantly higher in PACG patients than in POAG patients which is in concordance with a Chinese study.17 We believe that due to lack of awareness of glaucoma in Central India leads to late presentation of PACG patients which results in increased association with psychiatric comorbidities .
Risk Factors for Depression and Anxiety Disorder
Our study revealed that patients with a higher CDR and lower MD were more likely to suffer from depression. This results are in concordance with the studies by Mabuchi et al7 and Lim et al14 which concluded that increasing glaucoma severity (such as a lower MD in the worse eye) is a risk factor for depression in glaucoma. Our findings therefore highlight the importance of visual acuity, optic disc evaluation, and standard automated perimetry in the assessment of glaucoma patients.
Our study suggests that females are more likely to suffer from depression which is similar to results of a study done by Lim et al.14 But is in contrast to the observation made by Mabuchi et al7 where no relationship between depression and sex was found.
In our study, lower average score on the VFQ25 was found to be significantly associated with depression and anxiety disorder. Hence, routine screening of patients with glaucoma using the VFQ25 is suggested in glaucoma patients, especially those with severe disease. Assessment for possible psychiatric comorbidities and referral to the psychiatrist is advised in patients with low VFQ25 scores if required.
Assessment of QOL
The mean VFQ25 score in our study was 66.58±7.78 , Our findings suggests normal day to day activity is affected due to high prevalence of depression and anxiety disorders among glaucoma patients.
Topical Antiglaucoma Medications and Depression/Anxiety Disorders
There are conflicting reports in the literature as to whether the use of topical β-blockers results in depression. Bali et al23 reported that patients on topical β -blockers were 4.9 times more likely to have depression as compared with normal controls, whereas other studies7,24,25 did not find any increased risk of depression. In our study, there was no significant association between the use of topical β blockers/ prostaglandin analogues and depression (P=0.212) or anxiety (P=0.526). our results were also in concordance with a Singaporean study.14 Thus these topical antiglaucoma medications are not contraindicated in patients with depressive symptoms or a past history of depression.
Strengths and Limitations
This study has several strengths including it is the first study in India to report the prevalence and risk factors of depression and anxiety among patients with glaucoma along with their relationship with the QOL. Furthermore, unlike previous studies we used the HAM-D and HAM-A scores, which are the validated and gold-standard clinician administered screening questionnaires.
Our study has several limitations. First, as this was a cross-sectional study, causality on any of the reported associations could not be inferred. In future prospective study with a larger sample size are required to assess this associations. Second, all patients in this study were recruited from a single tertiary institution. This may cause selection bias, as our results may not be generalised to all patients with glaucoma. Third, as patients may have difficulty recalling previously experienced symptoms, this may cause interviewers to prompt patients, resulting in over reporting or under reporting of symptoms. We tried to minimize this social desirability bias by assuring participants of the anonymity and confidentiality of their information. In view of the above limitations, our findings may not be generalised to all glaucoma patients in India.
In conclusion, there is a relatively high prevalence of depression (50%) and anxiety disorder (42%) among glaucoma patients in Central India. Female glaucoma patients are more likely to suffer from depression. Other risk factors for depression include higher CDR, a lower mean VFQ25 score and primary angle closure glaucoma. Risk factors for anxiety disorder include lower mean VFQ25 score. Ophthalmologists should consider use of the VFQ25 questionnaire as an assessment for impairments in QOL in a glaucoma patient. If a glaucoma patient is at high risk of depression or anxiety disorder, a multidisciplinary management approach involving ophthalmology and psychiatry may be required.
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