Glaucoma and depression
There is no denying that quality of life is a critical component of a person’s wellbeing and their ability to live a fulfilled life. While the markers of quality of life may differ across countries and cultures, vision is consistently listed as one of its core drivers – so what happens to those whose sight is compromised because of glaucoma?
Professionals are becoming increasingly aware of an often silent issue amongst glaucoma patients – depression and anxiety. While the elderly are already at risk of these mental health problems, a loss of vision can accelerate these emotions and further isolate sufferers from getting assistance. It is more important than ever to be able to recognise the symptoms of depression and anxiety among patients and to know how to act to ensure patients are getting the support they need to live a fulfilled and comfortable life.
The following article explores the connection between glaucoma and depression as it pertains to eye health professionals, and is worth 0.25 CPD points. The article encompasses:
Please note that at the end of the article you will be asked to complete a short quiz to be eligible for the CPD credit.
The link between glaucoma and depression
Studies across cultures and countries have found strong links between glaucoma (as well as other vision-affecting conditions) and depression and anxiety. While the prevalence of depression among glaucoma patients differs between studies and countries, those with glaucoma consistently have higher levels of depression than those without.
In a 2012 study on glaucoma and quality of life, Dr. Ivan Goldberg and Dr. Simon Skalicky confirmed that factors such as progressive peripheral field loss, impaired visual function, and multiple treatments may contribute to depression – which in turn can affect a glaucoma patient’s quality of life (Skalicky & Goldberg, 2012).
“We were some of the first to prove the link between depression and glaucoma – but it’s not that surprising, considering that depression is linked with many chronic diseases,” explains Dr Skalicky, who is also President of Glaucoma Australia.
Drs. Goldberg and Skalicky found that as severity of field loss increased, the impact on health-related quality of life (QoL) rose in a linear fashion. Those with severe glaucoma had the lowest QoL scores. As vision decreases the psychological burden increases, together with a growing fear of blindness, social withdrawal from impaired vision, and depression.
The results of this study indicate a direct link between a person’s severity of vision loss and depression – as well as a concerning increase in the risk of depression if glaucoma is not managed effectively and vision worsens.
Other studies also found that the negative QoL effects of visual field loss may be influenced by knowledge of the condition, but not entirely: reduced QoL related to visual field loss was present in individuals who were previously unaware that they had glaucoma.
The link between glaucoma and depression has been highlighted in studies across the world. The 2018 Taiwanese study The association between glaucoma and risk of depression: a nationwide population-based cohort study followed patients for 11 years. The study found that those with glaucoma had a significantly higher risk of developing depression – the cumulative incidence of depression in the glaucoma group was 5.9% compared to 3.2% within the control group. The same study concluded this increased risk was caused by a combination of older age, the cost of healthcare, living alone, and substance abuse. It’s important to note that whilst substance abuse was included as a contributing factor of depression amongst glaucoma patients, a significant link between glaucoma medication and depression has never been found (Chen et al., 2018).
The effect of glaucomatous vision loss on depression levels has been observed in other studies. A 2013 German study Depression, Anxiety, and Disturbed Sleep in Glaucoma found that 18.3% of patients with visual field defects (including glaucoma) suffered from moderate or severe depression compared to only 2.7% of those without visual field defects. The authors of the study concluded that any presence of visual field defects as a result of glaucoma can be considered a major predictive factor of depressive and anxious symptoms, as well as sleep disturbance (Agorastos et al., 2013).
Risk factors for depression in patients with glaucoma
The prevalence of depression and anxiety among glaucoma patients can be linked to several risk factors. While some risk factors are a result of vision loss, other risk factors may affect any person – but are typically heightened by the feelings of isolation and loneliness that often occur as a result of a glaucoma diagnosis.
Social interaction and physical activity are common methods of maintaining emotional wellbeing and minimising risk of depression. When vision is compromised, glaucoma patients struggle to remain as active and agile as before as mobility is often severely impacted.
Those with glaucoma walk on average 10% more slowly than those with no vision complications, and glaucoma patients are slightly more likely to experience orientation problems and bumps or stumbles. This results in patients with glaucoma feeling unstable on their feet and uncomfortable getting themselves around. These impacts on mobility are also likely to increase with increasing glaucoma severity (Turano et al., 1999).
When patients have been influenced by a real or perceived inability to perform general daily activities – like reading labels, recognising faces, or driving – they are more likely to feel unhappy, lonely and depressed. They are less likely to practice physical activity, or travel to meet with friends or family. This puts their wellbeing at direct risk and isolates them from seeking support (Zhang et al., 2013).
While depression is common among older populations, it is critical to remember it is not a normal part of aging. Similarly, not all glaucoma patients are elderly, but enough are for it to pose an additional risk for depression.
Those of an advanced age are generally more at risk of depression. At this age people most commonly deal with the loss of a partner or loved one, the adjustment from work into retirement, and other illnesses alongside glaucoma. People of an older age are also at risk of being isolated or excluded from society – a phenomenon that is often heightened due to vision loss from glaucoma.
Please note that beta blockers (a class of medication used commonly in topical glaucoma treatment, and also used systemically for other health conditions) have, in some reports but not in others, been associated with a risk of depression, although it is not well understood and there are limited studies in glaucoma patients. Additionally, other medications patients may be taking for additional illnesses can pose an increased risk of depression – such as benzodiazepines, opioids, corticosteroids and anti-parkinsonain drugs (“Depression in elderly people,” 2008).
Signs and symptoms to look out for
Depression is more than just feeling low – but it can be difficult to identify sustained depressive behaviours and feelings.
While it is difficult to know a patient’s true thoughts if they’re not open about them, depression often manifests itself in certain identifiable behaviours and physical symptoms. Paying attention to minute behaviours when consulting a patient can offer a valuable opportunity to identify depression or anxiety among those with glaucoma.
The New Zealand Mental Health Foundation recognises a range of signs of depression – several may be identifiable in your patients (“Depression”, n.d.).
Decreased energy and a change in sleeping patterns
Depression commonly impacts a person’s sleeping patterns and habits. Some may sleep for longer but feel unrefreshed upon waking up, while others experience disrupted sleep or trouble getting to sleep at all.
Those with depression can experience decreased energy levels and feelings of immense fatigue – often making the smallest tasks feel overwhelming and difficult. You might notice a patient becoming increasingly exhausted each appointment you see them. In addition, notice if a patient finds a small task very intimidating or overwhelming – this might be a sign of exhaustion as a result of depression.
An irritable and agitated mood is a common sign of depression amongst men in particular. This might manifest as aggressive behaviour. People may also be irritable in their language or in their actions – either lashing out vocally at others or having an inability to settle or sit entirely still.
While aggressive behaviour is less common in women, some women may still experience it. Other women may experience a lack of confidence and feelings of insecurity, or feel pathetic instead (Martin et al., 2013).
Loss of interest and pleasure in activities
Those with depression often lose enthusiasm and motivation for activities that they used to find enjoyment from. This could be a general dissatisfaction with the world around them, or a reluctance to attend groups or hobbies that were once fun (e.g. choir, book clubs). Perhaps during a first appointment with a new patient, get some idea of what they do in their spare time so as to be able to ask them about how those activities are going at later appointments (“Depression & Anxiety Symptoms - Outer,” n.d.).
Similarly, those with depression can also lose the motivation to wash or shave properly, and may wear the same clothes often. If you notice a patient looking particularly messy or unkempt, they might fall under this category.
Difficulty thinking clearly
People with depression can find it hard to concentrate and may come across as distracted when communicating. Patients might seem distracted in an appointment, or may have difficulty answering your questions.
While depression and anxiety can go hand in hand, anxiety has its own symptoms that manifest differently in patients. Depression.org.nz identifies signs a person is struggling with anxiety as: (“Anxiety,” n.d.).
Depression.org.nz have outlined a further list of internal and external signs of depression and anxiety to look out for – you may find the list helpful in understanding the more intricate symptoms of depression (“Depression & Anxiety Symptoms - Inner,” n.d.; “Depression & Anxiety Symptoms - Outer,” n.d.).
Steps you can take to support patients with depression
Depression and anxiety are illnesses that no one should have to live with – especially those who are already managing the effects of glaucoma. So what steps can you take to help your patients who may have or be at risk of depression?
One of the most important things you can do to reduce your patients’ risk of depression is educate them around what to expect after a glaucoma diagnosis – not just from a medical perspective, but also in terms of the impact on their lifestyle.
“It’s not only depression but also anxiety – there are a lot of unspoken fears out there about glaucoma. A lot of that comes down to knowledge, and to past experiences with glaucoma,” shares Dr. Skalicky.
“For example, someone might be scared as they watched their mother go blind because of glaucoma – but today because they’ve been diagnosed early and treatments have improved since then, they will likely hold onto their vision.”
“Often patients leave those fears unspoken and doctors think that they’re completely fine when in reality the patient is freaking out – sometimes out of proportion to the level of the disease. They may have hardly any glaucoma but be convinced they’re going blind,” explains Dr. Skalicky. “We can work against that fear and loneliness by improving people’s understanding of what glaucoma is and how we can treat it.”
A Glaucoma Australia study found that patient-centred glaucoma-related education and support services may improve knowledge and can reduce anxiety for newly diagnosed glaucoma patients. All glaucoma patients should be adequately counselled about the nature of the disease and its management. (Skalicky, D’Mellow, House, Fenwick & Glaucoma Australia Educational Impact Study Contributors, 2017).
Aim to use plain English and remember to reiterate to patients the positives of actually getting a glaucoma diagnosis and the importance of following the proper treatments recommended.
As eye health professionals who see patients regularly, you are in an ideal position to monitor patients and their behaviours. Having an understanding of depression and being able to identify it within your patients is the first step to minimise the number of people suffering.
Although your focus will of course be on their eye health, try to incorporate questions about how they are doing on a day-to-day basis and find out how they are coping with the disease.
While depression can be a difficult subject to broach with a patient, handling the topic with a delicate nature will best keep a patient responsive and willing to consider additional treatment.
Dr. Skalicky and Dr. Goldberg’s study recommends the use of formal quality of life (QoL) assessment to ascertain patient satisfaction, detect increasing visual burden, or changes in overall functional ability over time. This can aid the clinician and patient to make difficult clinical decisions, and can guide choices to individualise therapy. What’s more, it allows the clinician to assess the impact of glaucoma on the patient’s life and then guide interventions, including those relating to mental health. A number of QoL assessment tools, also known as patient-reported outcome (PRO) questionnaires, are available to systematically assess the effects of glaucoma on patient activities and function. You can learn more about these tools in Dr. Skalicky and Dr. Goldberg’s study (Skalicky & Goldberg, 2012).
Some patients may just need to engage with others going through the same thing, to find support and reduce their feelings of isolation. Referring your patients to Glaucoma New Zealand and suggesting they join a local support group may be all that’s needed for those who are feeling lonely or isolated.
“Organisations like Glaucoma New Zealand and Australia can provide a lot of psychological support,” says Dr. Skalicky. “Patients can get a bit down due to a lot of psychological impacts. People need a lot of encouragement to attend appointments and use their drops, and they often feel like they’re a burden on their family. Glaucoma New Zealand provides a lot of support and encouragement through that process.”
Referring a patient to another professional who can support them and give them the mental support they need can enrich their lives – not only improving their wellbeing, but also improving their motivation to fight glaucoma and save their sight.
It’s generally best to refer a patient to their GP first, as they may need to rule out other illnesses (like vitamin deficiencies) that can have similar symptoms to depression. If their doctor also suspects the patient has depression, they’ll decide on the best course of action – which may include referral to a mental health specialist.
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Agorastos, A., Skevas, C., Matthaei, M., Otte, C., Klemm, M., Richar, G., & Huber, C. G. (2013). Depression, Anxiety and Disturbed Sleep in Glaucoma. The Journal of Neuropsychiatry and Clinical Neurosciences, 25(3), 205-213. https://doi.org/10.1176/appi.neuropsych.12020030
Anxiety - What you need to know. (n.d.). depression.org.nz. https://depression.org.nz/is-it-depression-anxiety/anxiety/
Chen, Y. Y., Lai, Y. J., Wang, J. P., Shen, Y. C., Wang, C. Y., Chen, H. H., Hu, H. Y., & Chou, P. (2018). The association between glaucoma and risk of depression: a nationwide population-based cohort study. BMC ophthalmology, 18(1), 146. https://doi.org/10.1186/s12886-018-0811-5
Depression. (n.d.). Mental Health Foundation. https://www.mentalhealth.org.nz/get-help/a-z/resource/13/depression
Depression & Anxiety Symptoms - Inner signs. (n.d.). depression.org.nz. https://depression.org.nz/is-it-depression-anxiety/inner-signs/
Depression & Anxiety Symptoms - Outer signs. (n.d.). depression.org.nz. https://depression.org.nz/is-it-depression-anxiety/outer-signs/
Depression in elderly people. (2008). Best Practice Journal, (11), 19-25. https://bpac.org.nz/BPJ/2008/February/depression.aspx
Martin, L.A., Neighbors, H.W., & Griffith, D.M. (2013). The Experience of Symptoms of Depression in Men vs Women: Analysis of the National Comorbidity Survey Replication. JAMA Psychiatry, 70(10), 1100-1106. doi:10.1001/jamapsychiatry.2013.1985
Skalicky SE, D'Mellow G., House P, Fenwick E; Glaucoma Australia Educational Impact Study Contributors. Glaucoma Australia educational impact study: a randomized short-term clinical trial evaluating the association between glaucoma education and patient knowledge, anxiety and treatment satisfaction. Journal of Clinical and Experimental Opthalmology, 46(3):222-231. https://www.ncbi.nlm.nih.gov/pubmed/28691363
Skalicky, S., & Goldberg, I. (2012). Quality of life in glaucoma patients. US Ophthalmic Review, 6(1), 6-9. http://doi.org/10.17925/USOR.2013.06.01.6
Turano, K. A., Rubin, G. S., & Quigley, H. A. (1999). Mobility performance in glaucoma. Investigative Ophthalmology & Visual Science, 40(12), 2803-2809. https://www.ncbi.nlm.nih.gov/pubmed/10549639
Zhang, X., Bullard, K. M., Cotch, M. F., Wilson, M. R., Rovner, B. W., McGwin, G., Jr, Owsley, C., Barker, L., Crews, J. E., & Saaddine, J. B. (2013). Association between depression and functional vision loss in persons 20 years of age or older in the United States, NHANES 2005-2008. JAMA ophthalmology, 131(5), 573–581. https://doi.org/10.1001/jamaophthalmol.2013.2597