UNC study on the relationship between dry eye severity, anxiety, and depression.
Have you been "there"?
Sombre thoughts on laser surgery, eye pain and two suicides. Where do we go from here?
Study: Dry eye relationship to depression, anxiety and stress in 16-35 year olds
I am longing to get my hands on the full study... but I decided I was too impatient and wanted to go ahead and post this. I can always blog about it again when I learn more. This study actually was the first thing in a long time to motivate me to dust off my LinkedIn password in hopes of being able to connect with the lead author.
Thoughtful analysis of the mental health impact of dry eye disease always catches my eye, and this one had the added attraction of specifically addressing young people.
The authors studied 211 subjects aged 16-35 (mean age 21) and found that while OSDI scores did not correlate with clinical signs of dry eye (as we know, that correlation is elusive!), they sure did correlate with quality of life, depression, anxiety and stress. Furthermore, the severity of dry eye symptoms picked up in those OSDI scores had more of an impact on depression than the other mental health aspects studied.
Eye Contact Lens. 2018 Aug 20. doi: 10.1097/ICL.0000000000000550. [Epub ahead of print]
Impact of Dry Eye on Psychosomatic Symptoms and Quality of Life in a Healthy Youthful Clinical Sample.
Asiedu K1, Dzasimatu SK, Kyei S.
Abstract
OBJECTIVE:
To determine the impact of dry eye on quality of life, depression, anxiety, and stress in a healthy youthful clinical sample.
METHODS:
This was a clinic-based cross-sectional study. Subjects were patients visiting the University of Cape Coast Eye Clinic for comprehensive eye examination. The age range for recruitment into the study was 16 to 35 years. Eligible participants completed three questionnaires namely the Ocular Surface Disease Index (OSDI), short version of the depression, anxiety, and stress scale (DASS-21), dry eye quality of life score (DEQS) questionnaire. All eligible participants underwent clinical assessment including meibomian gland expressibility, corneal staining, tear breakup time, and Schirmer 1 test. The Spearman correlation coefficient was used to determine the relationship between variables. Univariate and multivariate analyses of variance were used to determine the impact of the OSDI score on DASS-21 subscales scores and the dry eye quality of life scores.
RESULTS:
All 211 subjects who met the inclusion criteria were included in the analysis. The mean age for the entire sample was 21.6±3.0 years with a range of (17-31) years. Spearman correlation coefficient showed a statistically significant association between OSDI scores and DEQSs (P<0.001), anxiety scores (P<0.001), depression scores (P<0.001), and stress scores (P<0.001). Spearman correlation coefficient showed no statistically significant association between clinical test results and quality of life scores (P>0.05), DASS-21 subscales scores (P>0.05), except anxiety subscale and meibomian gland expressibility score (P=0.026). There were no statistically significant association between clinical test results and OSDI scores (P>0.05) except for the tear breakup time (P=0.018). Using Pillai's trace in the multivariate analysis of variance (MANOVA), there was a significant effect of OSDI severity classification on depression, anxiety, and stress subscales scores of the DASS-21, V=0.37, F(3, 207)=9.67, P<0.001. Furthermore, separate univariate analyses of variances on the outcome variables revealed a significant effect of OSDI severity classification on depression F(3, 207)=35.24, P<0.001, anxiety F(3, 207)=25.27, P<0.001, and stress F(3, 207)=13.08, P<0.001. The MANOVA was followed up with a discriminant analysis, which revealed three discriminant functions. When subjects were classified according to the OSDI grading of severity, there were a statistically significant difference between all levels of severity dry eye symptoms for the DEQSs (F(3, 207) = 63.9.3 P<0.001, η=0.48).
CONCLUSION:
The study showed that the severity of dry eye symptoms impacted on psychosomatic symptoms and quality of life. The study also revealed that the severity of dry eye symptoms impacted more on the depressive symptoms compared with other psychosomatic symptoms in this youthful clinical sample.
Depression and dry eye
Article: Plugs, depression and anxiety
It's all about the burning!
Another study just came out on depression and dry eye. But it's not really about depression and dry eye. (Old news.) It's about SYMPTOMS and depression, and of those symptoms, burning specifically.
Clinical signs of eye disease are the driving force behind how optometry and ophthalmology address dry eye. It's the clinical signs that drive what gets written in the chart and on the Rx pad - but it's the symptoms that drive the patients to the doctor, and failure to get relief for those symptoms that drive patients to doctors #2, #3 and #4 and at some stage into depression as well.
Dry eye patients are ruled by symptoms. (Call it pain, actually.) Pure and simple. We do not sink into clinical depression because of our TBUT, osmolarity or meibography scores or our ocular surface staining. We are driven there when we do not get relief from the unremitting burning sensation in our eyes. (It's not a hard concept to understand; sit there with your eyes open for 60 seconds and extrapolate that to "all day" and see how that prospect suits you.)
Eyecare professionals, we need you to listen, and not get so distracted by what you are, or, even more likely, are not seeing under your slit lamp that you fail to see the big picture needs of the patient seeking help.
Industry and FDA, we need you to listen and not get so hung up on the near impossibility of improving both signs and symptoms that you lose the bigger picture of the NECESSITY of bringing symptom relief to market.
Dear authors of the study linked below: Thank you, thank you, and thank you again for documenting this. We need every bit of increased emphasis on the role of dry eye symptoms that we can get, and especially that key word, "burning".
A thorough understanding of symptoms and patient goals should be driving dry eye research and dry eye treatment and management plans. It should also be playing a more central role in the FDA's dry eye drug approval process.
Am J Ophthalmol. 2018 Apr 12. pii: S0002-9394(18)30164-8. doi: 10.1016/j.ajo.2018.04.004. [Epub ahead of print]
How Are Ocular Signs and Symptoms of Dry Eye Associated with Depression in Women with and without Sjögren's Syndrome?
Gonzales JA1, Chou A2, Rose-Nussbaumer JR1, Bunya VY3, Criswell LA4, Shiboski CH5, Lietman TM1.
Abstract
PURPOSE:
To determine whether ocular phenotypic features of keratoconjunctivitis sicca (KCS) and/or participant-reported symptoms of dry eye disease are associated with depression in women participants enrolled in the Sjögren's International Collaborative Clinical Alliance (SICCA).
DESIGN:
Cross-sectional study.
METHODS:
Women enrolled in the SICCA registry from 9 international research sites. Participants met at least one of five inclusion criteria for registry enrollment (including complaints of dry eyes or dry mouth, a previous diagnosis of Sjögren's syndrome (SS), abnormal serology (positive anti-Sjögren's syndrome-related antigen A and/or B (anti-SSA and/or anti-SSB), or elevated anti-nuclear antibody and rheumatoid factor), bilateral parotid gland enlargement, or multiple dental caries). At baseline, participants had oral, ocular, and rheumatologic examination, blood and saliva collection, and a labial salivary gland biopsy (LSGB). They also completed an interview and questionnaires including assessment of depression with the Patient Health Questionnaire 9 (PHQ-9). Univariate logistic regression was used to assess the association between depression and demographic characteristics, participant-reported health, phenotypic features of Sjögren's syndrome, and participant-reported symptoms. Mixed effects modeling was performed to determine if phenotypic features of KCS and/or participant-reported symptoms of dry eye disease were associated with depression, controlling for health, age, country or residence, and gender and allowing for non-independence within geographic site.
RESULTS:
Dry eye complaints produced a 1.82-fold (95% CI 1.38-2.40) higher odds of having depression compared to being symptom-free (p < 0.001). Additionally, complaints of specific ocular sensations were associated with a higher odds of depression including burning sensation (OR 2.25, 95% CI 1.87-2.72, p < 0.001) compared to those without complaints. In both women with or without SS, the presence of symptoms of dry eyes and/or dry mouth rather than SS itself resulted in higher odds of depression. One particular ocular phenotypic feature of SS, a positive ocular staining score, was inversely correlated with depression.
CONCLUSIONS:
Participant-reported eye symptoms, particularly specific ocular sensations such as burning, were found to be positively associated with individual American College of Rheumatology/EUropean Union League Against Rheumatism (ACR/EULAR) SS criteria items.
Dry Eye and Mental Health
"dry eye" vs. DRY EYE
For the benefit of those scratching their heads over the dry eye and mental health connection, I thought I ought to preface this post with, once more, the distinction between mild, irritating-but-not-life-altering dry eye symptoms, and the type of full-on dry eye situation that sends your
scores rocketing and can so easily send your life into a tailspin when things aren't able to be brought under control within a reasonable amount of time.
Dry eye in all caps — and bear in mind I'm speaking in terms of
symptom
severity (i.e. what I experience), rather than
clinical
severity (i.e. what my doctor observes / test results), since they do so often diverge — is a completely different beast than the dry eye that just means putting in drops now and then.
DRY EYE is a high impact disease
cloaked in a trivial-sounding name.
Depression is par for the course.
I find myself constantly wanting to reassure people who are engulfed by depression that this is normal when you're at a certain stage in a major DRY EYE journey.
Now, if I seem to get a bit pedantic, circling back over and over to underscore definitions and distinctions, it's because some things really are frequently and stubbornly subject to misunderstanding — hence I am not going to bother apologizing for being repetitive.
So, first of all, when I say a major dry eye journey, I'm talking about major symptoms and major life impact, with or without an
equally
severe clinical condition identified by the eye doctor. Of course, the presence, and even more, the absence of major clinical conditions will play into the depression equation in their own special ways, but my real point is that many dry eye symptoms, when intense enough and/or persistent enough, are more than enough to routinely plunge people pretty far into depression.
Secondly, when I say depression, I'm not talking about feeling low for awhile — I'm talking about something more akin to major depressive disorder. Something that takes you down — way down, in a big way, and for a considerable period of time. A major life event, in fact.
Suicidal ideation is common.
I don't know that I even have anything more to say about this than the simple fact of it. I think that it's vital for all those who are experiencing it to know that, no, it's NOT just them, and no, it has NOTHING to do with them coping poorly. This is a shared, common experience for which there are sound reasons.
And here are some reasons.
I think of it as a dry eye crisis, brought on by the cumulative impact of several factors at once. Which combination of factors, of course, varies, but there are threads in common.
The crisis comes at different times for different people, and can recur. One common pattern is a relatively sudden onset of massive dry eye symptoms that quickly escalate in spite of (and perhaps occasionally because of) a whole slate of treatments thrown at them in the early months. After the first three or four doctors and several months of increasing struggles, it's hard to avoid starting to panic about the future. Another scenario is someone who has had significant dry eye, clinically, for years, and been on many treatments, but only recently had a worsening of their symptoms that has just become too much to cope with when coupled with a worsening prognosis.
The specifics and timeline vary for everyone, but the common factor is the global impact on the person, particularly their mental health.
Here are a variety of factors I commonly come across in interacting with dry eye patients — physical, emotional, practical, medical, financial — that I believe all can contribute to the escalation of anxiety and depression in people with dry eye. This is not an exhaustive list.
Pain.Note: I use this term very broadly to encompass dry eye sensations that many people would not necessarily class as pain, but which have the same effect. For example, constant burning, grittiness, etc. — in general sensations that go away only when your eyes are closed, at best. Chronic pain in general is well known to be associated with depression. Meantime, the cornea (the tissue most affected by dry eye) has more densely packed nerves than almost any other human tissue. It is designed to hurt — a lot — when under siege.
Loss of sleep. Many people with night dry eye wake up repeatedly through the night to apply additional lubricants, or are woken up by eye pain. Fear of going to sleep is a powerful factor for many, too, especially those with recurrent corneal erosions.
Impact on common daily activities. Many people with dry eye cannot use a computer, read, or do other close work for long, and find their hobbies interfered with. Outdoor activities become much more difficult due to pain from wind, and also (for many) light sensitivity.
Restricted driving. Ability to drive may be limited to a small range due to pain from air conditioning and heating. When vision is impacted, driving may not be possible at all.
Impact on work performance. Office environments and jobs with any adverse environment (outdoors, or indoors with low relative humidity) can impair basic work efficiencies. Many workplaces are not friendly to the concept of accommodations, and some patients cannot safely discuss medical issues with their employers.
Fear of job loss.
High cost of treatment. Many of the most common treatments are not covered by insurance and are very expensive. Most dry eye patients have to use a great deal of over-the-counter products, which are also out-of-pocket expenses that add up quickly.
Generalized financial fears. As dry eye goes on, and particularly if symptoms are continuing to worsen, there may be a broad fear of the future due to the likelihood of decreased ability to work and increased medical costs.
Symptoms not quantified. The perception that it's all 'subjective' leads to a host of problems, from minimizing their significance in general to failing to diagnose correctly. There are scientifically validated instruments available to quantify symptoms, but few patients know of them and they are still used infrequently in clinical practice.
Counterproductive nomenclature. "Dry eye" is with us forever, but... as I argued recently in another post, "dry eye" is a terribly trivializing misnomer affecting how patients think about themselves and how effectively they can communicate about their experiences with everyone from their eye doctors to their employers to their personal support system.
Misdiagnosis (and associated inappropriate treatments).
Inadequate information about one's diagnosis and prognosis.
Inadequate medical care. Patients commonly see several doctors before finding a specialist who can actually help, and in the meantime, may be spinning their wheels with unhelpful treatment and inadequate support while their condition is worsening.
Inadequate palliative care. Eye doctors as a whole are poorly equipped to educate patients about the non-medical or "lifestyle" steps they can take to address symptoms. For the first ten years I ran my DryEyeShop business, the most common phrase I heard from people on the phone after a conversation about simple remedies like moisture chambers was, "Why didn't my doctor tell me?"
Anger and/or guilt associated with elective surgeries. Anyone who has gotten dry eye from LASIK or elective blepharoplasty knows exactly what I am talking about. The psychological impact of an elective surgery gone awry is extraordinary and profound, even if uncomplicated by other factors — yet these patients always have other complicating factors, among which tensions with the surgeon may figure prominently, including as relates to failures of pre-surgical screening as well as post-operative treatment.
Sensation of isolation. While many people find understanding peers online, most people have no one near at hand who understands their experience.
Eyes being the organ affected. The innate fear of vision loss is well known and well documented. Any eye disease perceived as chronic can trigger this, consciously or otherwise — and more likely the latter.
Belief that one isn't coping well. I deliberately left this for last, in order for readers to see the irony of it in context. It's very, very common amongst those in their first six months to a year particularly when they have had no validation of the magnitude of what they're dealing with, so they have no context for it. All they have is how it's being reflected back to them by doctors, peers, and family, and if the wrong things are reflected back, the impact can further cripple their ability to advocate for themselves. It's also dangerous, for those who may be approaching suicidal, because they become unable to talk about the psychological impact of their experience, since they have every reason to expect it will be interpreted as a massively inappropriate, inexplicable response to their situation.