Prevalence of Depression and Anxiety in Neuro-Ophthalmic and Low Vision Patients

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Sanjana Jaiswal, Amna Ali, Mallika Tyagi, Rohini Kaur Chahal

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Sanjana Jaiswal

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Low-vision individuals are associated with substantial economic burdens, reduced quality of life, and loneliness. Studies have shown that these patients are at a greater risk for developing mental health problems like depression and anxiety compared to those without vision impairment. Additionally, visual impairment is associated with an elevated risk of suicidal tendencies. This article will summarize the current literature and cohort study findings about mental health conditions in low-vision patients and propose screening recommendations that will enable ophthalmologists to provide more comprehensive care, including appropriate referrals. This will help us better understand what factors, including age, nature, and onset of vision loss, treatment type, socioeconomic considerations, and others, impact mental health conditions such as depression and anxiety in a patient. Because vision loss is primarily considered a physical condition, the psychological ramifications of vision impairment are often overlooked.

Association Between Depression/Suicidal Ideation and Visual Impairment

Functional impairments such as vision loss are well-known to be associated with psychiatric conditions such as depression. In a national survey of US adults aged ≥20 years, the estimated prevalence of depression was higher among visually impaired adults (visual acuity <20/40 in the better eye) than among adults with normal visual acuity (10.7% vs. 6.8%). A large population-representative survey of 7548 participants found that baseline self-reported vision loss was significantly associated with future reports of depression (hazard ratio (HR), 1.33. Depression of any grade has been found in one-third of visually impaired older adults, approximately twice as high as the lifetime prevalence rates in the normal-sighted older population, where the prevalence of depressive symptoms is about 15%.

Elevated rates of depressive symptoms have been noted across a wide variety of visually impaired populations. Factors such as the nature and onset of vision loss can also affect the prevalence of depression among visually impaired populations. Certain eye conditions such as pseudoexfoliative glaucoma, which is associated with a faster rate of progression and poorer treatment response, has a higher rate of depression compared to primary open-angle glaucoma. In addition, another study showed that patients with primary angle-closure glaucoma had higher rates of depression than those with primary open-angle glaucoma.

Visual impairment is also a significant risk factor for suicidal ideation. A meta-analysis by Kim et al showed that the odds ratio (OR) of suicidal behavior for 17 studies  was 2.49. For 21 studies assessing suicidal ideation, the OR was 2.01. For 8 studies investigating the association between visual impairment and suicide death, the pooled OR was 1.89. Age group is also a predictive factor associated with suicidal behavior. These studies found that adolescents were at the highest risk. Another study by Park et al looking at the strength of association between visual impairment and suicidal ideations, plans, and attempts. After controlling for confounding variables, the adjusted odds ratio (AOR) for suicidal ideations, plans, and attempts were 1.36, 1.27, and 1.40 respectively.

Among patients with neuro ophthalmic conditions, a study looking at the association between neuromyelitis optica spectrum disorder (NMOSD) and depression found that out of 125 patients, more than a third (39.8%) suffered from depression which was moderate to severe in 51.5% of patients.

Association Between Anxiety and Visual Impairment

There is a high prevalence of anxiety among adults experiencing vision loss; however, the exact prevalence reported in the literature remains highly varied. According to a large 5-year longitudinal study evaluating 7,584 adults with self-reported vision impairment, the prevalence of anxiety symptoms was 27.2 percent. Estimates of clinically significant anxiety symptoms range from 8.7 to 15.6 percent.  Compared to their normal-sighted peers, visually impaired older adults report a significantly higher prevalence of anxiety and sub-threshold anxiety. More specifically, agoraphobia, social phobia, and generalized anxiety disorder are the most commonly reported anxiety disorders among visually impaired older adults. Visually impaired older adults also report a higher level of anxiety symptoms compared to their peers with other comorbidities, including diabetes and cardiovascular issues. A study conducted by Jampel et al. examining anxiety in newly-diagnosed glaucoma patients found that 35 percent of the study participants reported feelings of nervousness, anxiety, and stress. Interestingly, none of these patients had a visual acuity worse than 20/40, suggesting that the concerns associated with impending vision loss and living with a chronic degenerative disease can contribute to anxiety, even when current visual abilities are not impaired.

Some data indicates that the prevalence of anxiety symptoms may be dependent on the ocular pathology. Eramudugolla et al. found a significant relationship between anxiety symptoms and cataracts in elderly adults, but not for other eye diseases, including age-related macular degeneration and glaucoma, even after controlling for demographic and health characteristics. Another study by Ulhaq et al. examining the pooled prevalence of anxiety symptoms and disorders found that anxiety symptoms were most prevalent in uveitis (53.5%), followed by dry eye disease (37.2%), retinitis pigmentosa (36.5%), diabetic retinopathy (31.3%), glaucoma (30.7%), myopia (24.7%), age-related macular degeneration (21.6%), and cataract (21.2%) patients. Anxiety disorders had the highest prevalence in patients with thyroid eye disease (28.9%), followed by glaucoma (22.2%), and dry eye disease (11.4%). Early identification and management of anxiety in patients with chronic eye disease is crucial, especially in glaucoma patients; acute emotional stress can contribute to sudden rises in intraocular pressure and is associated with ocular hypertension.

Among patients with neuro-ophthalmic diseases, 81.2 percent presented with mild to severe symptoms of depression, anxiety and stress, and a positive correlation was observed between the severity of visual impairment and the incidence and severity of psychic symptoms.

Screening for Depression and Anxiety in Ophthalmic Clinic Settings

Studies have demonstrated a high prevalence of depression and anxiety in older patients with ophthalmology conditions that result in and exacerbate low vision consequences. There is also an identified association between individuals with visual impairment and an increased risk of suicidal tendencies. These low vision consequences include diminished quality of life, accelerated functional decline, nursing home placement, and a higher fall risk. However, the risk of depression and anxiety is not limited to the elderly population. A recent CDC study showed that younger patients with vision loss had five times the risk of depression and anxiety compared to older patients. These facts have illuminated a need for depression, anxiety, and suicide screening recommendations in low vision populations of all ages.

The US Preventative Services Task Force does not have clear recommendations for depression, anxiety, and suicide risk screenings for adults. There are many screening tools, and there is not one that is applicable to all patients. It is imperative that low vision practitioners obtain a detailed history and create a genuine connection with the patient before making referrals. When selecting screenings it may be best to be pragmatic, considering the specific clinic’s population and work flows, as well as physician familiarity with screening tools. Screenings should only be undertaken if there is a strong commitment to providing treatment and follow-up.

The following self-report screenings were identified as the most commonly used in various systematic reviews and meta-analyses examining the prevalence of depression, anxiety, and suicide risk among adults.

1. Geriatic Depression Scale (GDS): The GDS is one of the most used screenings to identify depression among older adults. The GDS long-form (GDS-30) consists of 30 yes/no questions, in which participants respond to how they felt in the past week. Of the 30 questions, 15 questions that had the greatest correlation with positive predictors of depression were selected to make up the GDS short-form (GDS-15). This questionnaire takes 5-7 minutes to complete. A score of >5 is suggestive of depression and warrants a follow-up comprehensive assessment. A score of >10 is almost always indicative of depression.  A worsening of visual acuity is associated with a greater number of depressive symptoms on the GDS-15.  
2. Beck Depression Inventory (BDI): The BDI is a 21-item self reporting questionnaire for evaluating the severity of depression in normal and psychiatric populations. Patients are evaluated on a 4-point scale from 0 (absent symptom) to 3 (severe symptom). The values are added and scores indicate whether the patient suffers from minimal depression, mild depression, moderate depression, or severe depression. There is a shorter version for primary care use, containing 7 items (Beck Fast scan) that each correlate with a major depressive symptom over the last 2 weeks. The US Preventive Services Task Force recommends the Beck Fast scan.
3. 9-items Patient Health Questionnaire (PHQ-9): The PHQ-9 is widely used in nonpsychiatric settings and consists of 9 questions that evaluates how much a symptom has bothered them in the past 2 weeks on a scale of 0 (not at all) to 3 (nearly every day). This screening also can be used to identify high-risk patients for suicide risk.
4. Center for Epidemiologic Studies Depression Scale (CES-D): The CES-D is widely considered a popular brief scale for assessing depression and is used as a measure of depressive symptomatology among patients with certain chronic conditions as well as a general diagnostic measure of depression. It consists of 20 questions about frequency of symptoms (0-3) in the prior week. After summing the responses for each question, the general cutoff for depression is greater than 16.  
5. Zung Self-Rating Depression Scale (SDS): The SDS consists of 20 questions and assesses the psychological and somatic symptoms of depression, and it is used for screening and measuring depression. After patients rate each item according to their feelings in the prior week using a 4-point Likert scale, the results are converted into a percentage. Some studies recommend the general cutoff for depression is greater than 50.
6. Hospital Anxiety and Depression Scale (HADS): The HADS consists of 14 questions which detects symptoms of depression and anxiety in patients attending medical outpatient clinics and excludes somatic symptoms.  The two subscales are separated into 7 questions about depression and 7 questions about anxiety, with each question rated from 0-3, with 0 indicating no depression/anxiety and 3 indicating the highest severity of depression/anxiety. The cutoff for the two subscales are 8 or greater points, indicating significant symptoms of depression/anxiety. Using the HADS as part of a low vision patient’s management plan has been proven beneficial.
7. Goldberg Anxiety and Depression Scale (GADS): The GADS consists of 18 yes/no questions, subdivided into 9 about depression and 9 about anxiety. Patients with a summed anxiety score of 5 and greater, or a summed depression score of 2 and greater have a 50% chance of having clinically significant disturbances.  
8. State-Trait Anxiety Inventory (STAI): The STAI screening can be used in clinical settings and can help differentiate anxiety from depression. It consists of 20 questions assessing state anxiety and 20 items assessing trait anxiety. A 4-point scale is used for each question, from almost never to almost always, and higher scores indicate greater anxiety levels.  
9. General Anxiety Disorder-7 (GAD-7): The GAD-7 screening consists of 7 problems that are ranked on a scale of 0 (not at all) to 3 (nearly every day), denoting how frequently a problem has occurred in the past 2 weeks. After summing the ranks, one can determine severity of anxiety – minimal, mild, moderate, or severe.
10. Columbia-Suicide Severity Rating Scale (C-SSRS): The C-SSRS is a detailed screening for outpatient settings that assesses suicidal ideation, intensity of ideation, and suicidal behavior. There are 2 yes/no baseline questions, encouraging patients to describe their answers, followed by other sections that should be answered if any of the first couple questions are answered “Yes”. It can be used as an initial screening.  

There are limitations to self-reported screenings from a professional and a patient perspective, especially for mental health topics. Patients are a barrier to treating depression – practitioners feel as if they are often reluctant to discuss depression because of the social stigma related to mental health, leading to a reluctance in practitioners properly screening patients with a standardized method. Practitioners also lack confidence in their knowledge and skills to address depression. They express concerns about making incorrect judgements about patients that may lead to unnecessary distress. Some practitioners are not aware of the appropriate referral pathways for patients with suspected depression, instead choosing to avoid the topic altogether.  To combat this, researchers have proposed screening service guidelines and training. Studies have shown that practitioners take significantly more action in response to suspected depression following training and perceive fewer barriers to addressing depression. It is possible that training low vision practitioners for anxiety and suicide risk screenings may also lead to these positive results, although further studies must be done.

Role of Low Vision Rehabilitation and Support Group Services

Low Vision Rehabilitation (LVR) has been suggested as an appropriate treatment for mental health conditions like depression and anxiety secondary to a low vision diagnosis. The goal of LVR is to reduce vision-related disability by maximizing the potential of remaining vision. Comfortably using assistive devices, working on orientation and mobility skills, and learning compensatory strategies are improved at LVR. Despite the clear benefits of LVR, it is an underutilized service in ophthalmology. Patients with mental health issues are less likely to utilize low vision services. Other barriers include patient denial for the need of low-vision care, poor physical health, lack of transportation, and lack of referrals. In fact, only 5-10% of patients who qualify for low vision services end up obtaining them. This indicates limitations on the sides of the patient and of the healthcare system at large. In order to improve, physicians need to change and standardize referral patterns and increase patient awareness and knowledge of LVR resources.

Although LVR is a useful tool that has been shown to improve mental health outcomes in patients, fewer than 25% of LVR providers in the United States offer any psychological treatment. Therefore, a greater emphasis should be made on the potential benefits of low vision treatment that focuses on the psychological manifestations of low vision. One form of psychological treatment is patient support groups. For a patient with low vision, both the lived and perceived stigma encountered when interacting with individuals who have normal vision can hinder social participation and affect their ability to function optimally. Group identification, which can be found in support group settings, is predictive of greater social support, a rejection of stereotypes, and increased resistance to stigma. Patients' perceived social support may be more significant than visual acuity when it comes to clinical depression and anxiety. It has been shown that peer support interventions are effective in alleviating symptoms of depression. Further, a literature review paper examined the effectiveness of support groups and found them particularly helpful for patients suffering from mental illness, including anxiety and depression. Support groups have also been found to benefit suicidal individuals and suicide survivors. In the future, research should be done to determine a definitive link between support groups and low vision patients. This research is particularly important for patients with neuro-ophthalmology diagnoses, as over 80% of these patients experience mild to severe mental health symptoms.