Prevalence of Anxiety and Depression in Patients With Primary Glaucoma in Western India

Précis: Glaucoma can cause disturbance in psychological and emotional functioning of patients, leading to anxiety and depression, even early in the disease. Identification and management of these problems should be included as a part of the holistic approach for patient care. Purpose: The purpose of this study was to assess the prevalence of anxiety and depression in patients with primary glaucoma using a standard validated questionnaire. Methodology: A cross-sectional prevalence study was carried out on 200 patients attending the glaucoma outpatient clinic at a tertiary care eye hospital in Pune, India. After obtaining written consent, all patients underwent a thorough ophthalmic examination. Those with primary glaucoma were included in the study and classified on the basis of the Hodapp-Parrish-Anderson criteria. Participants were asked to respond to the Hospital Anxiety and Depression Scale (HADS) questionnaire, and responses were analyzed statistically. Results: The mean HADS-Anxiety score was 4.5 (SD=3.4), while HADS-Depression was 4.1 (SD=3.8). The severity of the disease was associated with significantly higher HADS scores. Mean HADS-Anxiety scores were 3.1 (SD=2.9) for mild glaucoma, 4.4 (SD=2.6) for moderate, and 7.7 (SD=3.0) for advanced disease (P<0.001). Similarly, mean HADS-Depression scores were 2.0 (SD=2.6), 4.2 (SD=3.0), and 8.3 (SD=3.3), respectively for mild, moderate, and severe glaucoma (P<0.001). Based on HADS scores, a third of patients (34.5%) were symptomatic for anxiety or depression, out of which 25 (12.5%) could be classified as definite cases. Duration of treatment had no association with HADS scores. Conclusions: An association exists between the amount of visual loss among patients with glaucoma and symptoms of anxiety and depression, irrespective of disease duration. This information may help to choose treatment approaches most likely to be beneficial to the patients.

G laucoma is a chronic progressive disease that can lead to visual field deterioration and potential blindness if left untreated. It is one of the leading causes of irreversible blindness, affecting > 12 million people in India alone. 1 The potential blinding nature of the disease can have negative psychological effects on the patient. 2 Factors such as impairment in daily activities, financial burden of the treatment, lack of disease awareness and the associated social stigma have been implicated with negative emotions among patients. 3,4 All these factors can impair selfconfidence, which may in turn cause demoralization, leading to treatment noncompliance and impaired quality of life. 5 Anxiety and depression are 2 common psychological disturbances that can manifest in patients with such chronic conditions. Studies done previously have demonstrated the presence of anxiety and depression in significant number of patients with glaucoma. 4,6-10 However, the bulk of the data available is from the studies done in other parts of the world. To the best of our knowledge, very few studies have investigated the burden of anxiety and depression among glaucoma patients in a country as vast as India. With the rising number of patients and the need for lifelong treatment, it is essential to keep a tab on the psychological and emotional status of the patient.
Various tools are available to assess the psychological status of the patient. We utilized the Hospital Anxiety and Depression Scale (HADS), developed by Zigmond and Snaith, 11 for our study. With this study, we aim to assess the prevalence of psychological disorders in patients with primary glaucoma.

METHODOLOGY
We conducted a cross-sectional study at a tertiary care eye center in Pune, Maharashtra, India. Prior approval from the institutional ethics committee was obtained. All new and follow-up patients attending the glaucoma outpatient department of the hospital between January 2018 to December 2018 were explained in detail about the study, and informed consent was taken. After obtaining a detailed history, all patients underwent thorough examination including slit-lamp examination, Goldman applanation tonometry, gonioscopy, pachymetry, dilated fundus examination, and standard automated perimetry. The examination was performed by trained glaucoma specialists (K.V.K. S. and V.C.). Patients with secondary glaucoma, age less than 25 or more than 80 years, and those with other ocular comorbidities significantly affecting visual function were excluded. We also excluded patients having preexisting physical disabilities or psychiatric conditions, such as anxiety or depression, as well as those on systemic medications that have potential psychiatric side effects. Hodapp-Parrish-Anderson criteria was applied to classify patients into mild, moderate, and severe. 12 Also, patients were grouped according to the duration of treatment into 3 groups-those with a duration of treatment <12 months were grouped in group 1, those between 1 and 3 years in group 2, and finally those with duration > 3 years in group 3. DOI: 10.1097/IJG.0000000000001935

HADS was developed by Zigmond and Snaith in 1983.
It is a self-administered questionnaire containing 2 set of 7 questions each, 1 for anxiety and 1 for depression (HADS-A for anxiety and HADS-D for depression), respectively. Each question is graded on a 4-point Likert scale (0 to 3). The lowest score for each subset of 7 questions is 0, and the maximum is 21. Higher scores indicate higher levels of anxiety and depression. A score of > 10 on HADS-A or HADS-D are considered as a definite case, while between 8 and 10 are considered as borderline or doubtful cases. 9,11,13 All patients were asked to respond to the HADS questionnaire individually, and scoring for each response was done. The data obtained was recorded and analyzed statistically using SPSS 21.0 for Windows. The Tukey honestly significant difference test was used for multiple comparisons. 14

RESULTS
A total of 200 patients, fulfilling the inclusion criteria, were included in the study. Of the 200 patients, 113 were males and 87 were females. The mean age of the study group was 59.2 years (SD = 12.6 y). Basic demographic details of the study population are mentioned in Table 1. The mean HADS-A and HADS-D scores for the study group were 4.5 (SD = 3.4) and 4.1 (SD = 3.8), respectively. Prevalence of definite cases of anxiety and depression using the HADS scale were found to be 6.5% (13/200) and 6% (12/200), respectively (Figs. 1, 2). A total of 44 patients (22%) were found to be borderline or doubtful cases for anxiety or depression on HADS scale. No significant difference was observed in HADS-A and HADS-D scores between males and females (4.

DISCUSSION
Few studies have been undertaken in recent decades to measure the prevalence of psychological conditionsanxiety and depression in patients with glaucoma. 4,[6][7][8][9][10]15 These have provided us with some insight into patients' psychology and thought process. Through this study, we tried to assess the prevalence of anxiety and depression in Indian population with glaucoma. We utilized the HADS questionnaire as a measurement tool, like some of the other studies. It has the advantage of measuring anxiety and depression simultaneously.
The original HADS developers had recommended 2 cutoff values for the questionnaires. The lower cutoff ( ≥ 8) denotes doubtful cases or those mildly symptomatic, while    the upper cutoff ( > 10) denotes definite cases. 11 Various investigators have chosen either of the cutoff values for their analysis. 6,7,9,15 However, we decided to consider both upper and lower cutoff values in our result. Choosing the upper cutoff value ( > 10) enables us in selecting the cases with a high probability of having a mood disorder, thereby reducing the false positives, while the lower cutoff value gives an estimate of all possible cases that may have symptoms of anxiety or depression. 11 Studies done in various parts of the world have demonstrated great variations in estimating the prevalence of anxiety and depression in patients with glaucoma. Estimates from studies done in different countries range it from 6% to 64% for anxiety and 7% to 42% for depression. 4,6,7,9,10,[15][16][17][18] In our study, the prevalence rates of anxiety as well as depression were comparable with a study done by Rezapour et al 16 in Germany. These variations might be attributed to factors such as regional variation in study populations and the different questionnaires used for screening. Our study data demonstrated a higher prevalence of anxiety and depression in patients with glaucoma than reported in the general Indian population (3.3% and 3.3%, respectively). 19 While interpreting the results, it should be borne in mind that the definite cases on HADS scale (HADS score > 10) may just be representing the tip of an iceberg with many subclinical cases falling in doubtful or noncase categories. Also, it was observed that the addition of borderline or doubtful cases in the data further increases the prevalence and hence the disease burden. In our study, on including the borderline cases lying within lower cutoffs of HADS (8 to 10), the prevalence of anxiety and depression doubled to 14.5% (29/200) and 20% (40/200), respectively (Figs. 1, 2).
As the disease progresses, patients start experiencing difficulty in carrying out routine day-to-day activities due to deterioration of visual function. 6,20,21 This, in turn, affects their psychology causing negative emotions such as low selfesteem, lack of confidence, anxiety as well as depression. We also observed a significant increase in mean HADS scores with worsening disease severity from mild to severe. Similar trends were observed in studies done in China, 6,7 Singapore, 4 Japan, 8 and Nigeria. 17 Diagnosis of glaucoma could be an emotionally stressful experience for the patient. Some of the previous studies have documented negative emotional response even in patients with a recent diagnosis of glaucoma. Odberg et al 3 reported negative emotions in > 80% cases with newly diagnosed glaucoma. They attributed these negative emotions to fear of blindness caused by lack of disease comprehension among the patients. In our study, we did not find any significant difference in the HADS scores of patients within different disease duration groups, indicating that negative emotional response was not directly related to disease duration. Even patients who are recently diagnosed can have negative thoughts on just learning about the diagnosis. Similar results were obtained in some of the other studies assessing the psychological and emotional state of glaucoma patients. 17,[22][23][24] This study demonstrates an association between the severity of glaucoma and psychological impairment in patients. We also observed a significant prevalence of anxiety and depression in Indian patients with glaucoma which was higher than the overall prevalence rate in the general population. Considering the number of individuals with glaucoma, these prevalence rates would translate into huge numbers. Other studies done globally have also reported similar findings. 4,6,7,9,15,17 Presence of anxiety, depression,    and other negative thoughts may undermine a patient's selfconfidence, leading to poor treatment compliance and impaired quality of life. Hence, the role of proper patient education and counseling and their possible benefits should be evaluated further. Patients should be made aware about the disease process and the treatment options available at the time of diagnosis. Distributing descriptive pamphlets or brochures for patient information could be an effective method and can be a subject of further research. Treating clinicians must put emphasis on addressing the emotional and psychological issues that a patient may face as a part of a holistic approach to patient care. Assistance from a trained psychiatrist or psychologist can be sought for those showing signs of depression or anxiety. However, there were a few limitations in our study. The study sample was selected from a tertiary eye care hospital in an urban area and may not adequately represent the Indian population with glaucoma. Since it was a crosssectional study, we did not include a control group for comparison. Although the association between disease severity and psychological impairment seems to be causal, establishing a causality would have been difficult with the current study design. Moreover, we did not analyze the effect of other factors such as socioeconomic and education status of patients on anxiety and depression, which we hope to take up in future studies.

CONCLUSIONS
An association exists between the amount of visual loss that occur in people with glaucoma and symptoms of anxiety and depression. Presumably, this information needs to be known by both health professionals and affected patients to choose more holistic treatment approaches most likely to be beneficial to the patients.