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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 3  |  Page : 315-321

Factors associated with depression and anxiety among glaucoma patients in a tertiary hospital South-East Nigeria


1 Department of Ophthalmology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
2 Department of Psychological Medicine, College of Medicine, University of Nigeria Teaching Hospital Ituku-Ozalla, PMB 01129, Enugu, Nigeria
3 Department of Ophthalmology, Enugu State University of Technology Teaching Hospital, Enugu, Nigeria
4 Department of Physiology, Faculty of Basic Medical Science, University of Nigeria, Enugu Campus, Nigeria

Date of Submission18-Jun-2019
Date of Acceptance07-Dec-2019
Date of Web Publication5-Mar-2020

Correspondence Address:
Dr. N Z Nwachukwu
Department of Ophthalmology, University of Nigeria Teaching Hospital, PMB 01129, Ituku-Ozalla, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_140_19

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   Abstract 


Objective: To explore the factors associated with depression and anxiety among glaucoma patients. Subjects and Methods: This was a cross-sectional study involving adult glaucoma patients, who attended the eye clinic of Enugu State University Teaching Hospital, Parklane, Enugu, from April to September 2018. In total, 182 glaucoma patients with no other significant ophthalmic or medical conditions were recruited. Information on their socio-demographic and clinical characteristics was obtained using a close-ended, interviewer-administered questionnaire. Detailed ophthalmic evaluation to characterize the glaucoma was done. Depression and anxiety were assessed using the hospital anxiety and depression scale. Data were analyzed using SPSS version 21. Bivariate analysis was done to identify factors associated with depression and anxiety. The level of significance was at P < 0.05. Results: The participants were mainly females, 108 (59.3%), married, civil servants with tertiary education and mean age of 59.7 ± 13.3 SD years. Majority of them had advanced stage of primary open angle glaucoma. Eighty (44%) of the participants had anxiety, while 76 (41.8%) had depression. Severe/blind stage of glaucoma and reduced visual acuity were significantly associated with anxiety and depression; occupation (trading) and intraocular pressure of <21 mmHg also significantly associated with depression. Conclusion: The prevalence of anxiety and depression among glaucoma patients in Enugu was high. Severe/blind stage of glaucoma and reduced visual acuity were the most important factors that associated with both anxiety and depression. Incorporating a psychological health approach to glaucoma care especially in patients with severe glaucoma and reduced visual acuity may promote effective communication between clinicians and patients and treatment adherence.

Keywords: Anxiety, depression, glaucoma


How to cite this article:
Onwubiko S N, Nwachukwu N Z, Muomah R C, Okoloagu N M, Ngwegu O M, Nwachukwu D C. Factors associated with depression and anxiety among glaucoma patients in a tertiary hospital South-East Nigeria. Niger J Clin Pract 2020;23:315-21

How to cite this URL:
Onwubiko S N, Nwachukwu N Z, Muomah R C, Okoloagu N M, Ngwegu O M, Nwachukwu D C. Factors associated with depression and anxiety among glaucoma patients in a tertiary hospital South-East Nigeria. Niger J Clin Pract [serial online] 2020 [cited 2020 Apr 6];23:315-21. Available from: http://www.njcponline.com/text.asp?2020/23/3/315/280018




   Introduction Top


Globally, glaucoma is the most common cause of avoidable, irreversible blindness with an estimated prevalence of 3.54%.[1] In Africa, a higher prevalence of 4.79% was reported.[1] It is a chronic sight-threatening disease of the optic nerve with characteristic visual field defects. It is usually asymptomatic at the early stages and gradually progresses to irreversible blindness.[2] It requires a life-long use of ocular hypotensive agents, even after surgeries.[3]

In Nigeria, glaucoma accounted for >16% of blindness.[4] It is further characterized by misconceptions and poor knowledge of the disease resulting to late presentation of advanced stages of primary open angle glaucoma (POAG).[5],[6] The challenges include cost of treatment, availability, and accessibility to care, poor adherence to medications, and loss to follow up.[7],[8] These challenges coupled with the fear of blindness[7] psychologically disturb the patients and reduces their quality of life.[9],[10]

Psychological disturbance in glaucoma patients is a double tragedy as effective communication between clinicians and patients is lost. Confidence and treatment adherence are compromised; therefore, progression to irreversible blindness may become inevitable.

Depressive disorders are characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration. Depression can be long-lasting or recurrent, substantially impairing an individual's ability to function at work or school or cope with daily life.[11] The proportion of the global population with depression in 2015 is estimated to be 4.4%.[11] Anxiety disorders refer to a group of mental disorders characterized by feelings of anxiety and fear, including generalized anxiety disorder, panic disorder, phobias, social anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder.[11] As with depression, symptoms can range from mild to severe. The duration of symptoms typically experienced by people with anxiety disorders makes it more a chronic than episodic disorder. The total estimated number of people living with anxiety disorders in the world is 264 million.[11] Both depression and anxiety are more common in females.

Researches have shown that glaucoma patients are more prone to having anxiety and depression.[12],[13],[14],[15] In a review of depression in eye diseases, Yajing et al.[16] reported that glaucoma has a prevalence of 25%; only dry eyes disease had a higher prevalence. Predictive factors were younger age,[17] being unmarried,[12] glaucoma severity,[18],[19],[20] female gender,[17] economic burden,[17] for anxiety; while female gender and being unmarried,[13] duration of disease,[17] comorbidity with cerebrovascular disease, concomitant use of systemic beta blockers, and calcium channel blockers were associated with depression.[15]

Nigerian studies[9],[10] are few and did not investigate the factors associated with depression and anxiety among these patients. To the best knowledge of the researchers, none has been reported in the South-East region of Nigeria on risk factors for glaucoma blindness.[21] This study was, therefore, aimed at determining the prevalence of depression and anxiety among glaucoma patients in a tertiary hospital in Enugu, South-East region of Nigeria and to explore the factors associated with them in order to generate evidence-based data to incorporate a psychological health approach to glaucoma care.


   Subjects and Methods Top


Study setting

This study was carried out at the Enugu State University Teaching Hospital, Park lane, Enugu. It is located in Enugu state, within the tropical rainforest climatic zone. It provides tertiary healthcare services in all major medical and surgical specialties, undertakes undergraduate and postgraduate medical training, and conducts research. Its Ophthalmology Department is staffed by consultant and trainee ophthalmologists, optometrists, ophthalmic technician, and ophthalmic nurses. It provides inpatient and outpatient promotive, preventive, curative, and rehabilitative eye care services to the inhabitants of Enugu state, the other four states in South-East geopolitical zone, and some states in North-Central and South-South, Nigeria.

Subjects

Consecutive, consenting 182 glaucoma patients, aged 18–72 years, who met the eligibility criteria and presented at the eye clinic within the study period, April to September 2018.

Eligibility criteria

Glaucoma patients without additional diagnosis of other blinding eye disease or chronic medical conditions, who attended the eye clinic during the study period and voluntarily gave written informed consent for participation.

Exclusion criteria

Current diagnosis of substance abuse or addiction, lifetime diagnosis of psychotic/affective disorder, intake of prescribed sleep medication, antidepressants, antipsychotics, immunosuppressant and oral cortisone, and inability or unwillingness to conform to the study protocol.

Ethics

Prior to the start of the study, ethics clearance compliant with 1964 Helsinki Declaration was obtained from Health Research Ethics Committee (HREC) of the University of Nigeria Teaching Hospital Ituku-Ozalla Enugu.

Study design

This was a cross-sectional, descriptive, hospital-based survey. Information on the subjects socio-demographic characteristics, clinical characteristics were collected using a close-ended, interviewer-administered questionnaire. Detailed ophthalmic evaluation to characterize the glaucoma was done. Depression and anxiety questionnaires were also administered.

Study instruments

The Hospital Anxiety Depression Scale (HADS) developed by Zigmond and Snaith[22] to detect anxiety and depression in a general medical population of patients[22] was used in the study. It is a 14-item self-report instrument that consists of seven items each for depression and anxiety. The responses are based on the relative frequency of symptoms over the past week. The HADS is devoid of somatic symptoms hence its usefulness in assessing the impact of physical illness on psychological wellbeing.[23] Scores are rated on a four-point scale ranging from 0 to 3, with 21 as the highest score. For the stringent and robustness of case-findings, a cut-off point of ≥11 and above in either or both scales of anxiety and depression indicates probable anxiety and or depression. While 8–10 on both subscales indicates borderline case, 0–7 indicates no anxiety or depression. The scale is designed as a screening tool rather than a clinical diagnostic tool and was used in this study as a screening instrument to flag probable anxiety and depression illness. It has also been found to perform well in assessing the severity in already diagnosed persons with depression or anxiety.[24] The instrument has been validated and widely used in various settings in Nigeria[25] and among ophthalmic patients.[13],[23],[26]

Study procedure

Following a voluntary written informed consent, the study questionnaires were administered and the following assessments were carried out on each participant sequentially: visual acuity (VA), perimetry, pachmetry, gonioscopy, tonometry, and optic disc assessment with +90D lens. The right eye was first assessed, then the left eye.

VA was done with the log MAR chart and recorded for every participant. Reliable perimetric reports done with static automated perimetry (SAP; Humphrey Visual Field Analyzer 30-2; Humphrey Instruments, San Leandro, CA, USA) using a 30-2 threshold program (HFA30-2) with the SITA Standard strategy within the last three months prior to commencement of the study were retrieved from the patients' records. Otherwise, the central visual field of the participants was done by an experienced technician using the Humphrey Visual Field Analyzer. Central corneal thickness values were retrieved from patients' records; else, ultrasonic pachymetry (Sonomed) was performed by an experienced operator under topical anesthesia with tetracaine 1%. Measurements were obtained five times in the center of the cornea and the average reading was recorded. The Goldmann applanation tonometer (Haag-Streit 900; Haag Streit, Koeniz, Switzerland) was used to measure the intraocular pressure of each participant in the mornings between 8 and 10 am. Gonioscopy was done using a four-mirror goniolens on each participant as well as optic disc examination with +90D lens by a glaucoma specialist, who also staged the severity of glaucoma according the guidelines of the American Academy of Ophthalmology.[27]

Study definitions

A score of ≥8 in either or both of the two subscales (anxiety/depression) was regarded as a case in this study.

Mild or early stage glaucoma

Optic nerve head abnormalities consistent with glaucoma, but no current defect on the visual field with SAP and mean deviation (MD) less than −6 dB.

Moderate stage

Optic nerve abnormalities consistent with glaucoma and glaucomatous visual field abnormalities in one hemifield and not within 5 degrees of fixation with MD −6 to −12 dB.

Severe stage: Optic nerve abnormalities consistent with glaucoma, glaucomatous visual field abnormalities in both hemifields and/or loss within 5 degrees of fixation in at least one hemifield with MD more than −12 dB.

Data management

Data were collected, cleaned, edited, coded, and analyzed using the Statistical Package for Social Sciences (SPSS) computer software (2011, IBM SPSS Statistics for Windows, Version 20.0: IBM Corp., Armonk, NY). It was categorized into sociodemographic variables and clinical profile and subjected to descriptive statistical evaluation to yield frequencies, percentages, and proportions. Bivariate analysis was used to identify the factors affecting depression and anxiety. The level of significance was placed at P value of <0.05.


   Results Top


The participants were mainly females, 108 (59.3%), married, civil servants with tertiary education with a mean age of 59.7 ± 13.3 years [Table 1]. Most of the participants had advanced glaucoma [Table 2].
Table 1: Sociodemographic characteristics of the participants (n=182)

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Table 2: Clinical characteristics of the participants (n=182)

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Eighty (44%) participants had anxiety, whereras 76 (41.8%) had depression.

Depression was observed more in females than males [Table 3]. The most important factor that affected anxiety was reduced visual acuity from moderate to severe/blind (P < 0.001), followed by advanced/blind grade of glaucoma (P < 0.04) [Table 4]. Other factors that affected anxiety, though insignificantly were duration of the disease, occupation and non-formal education among others [Table 4].
Table 3: Prevalence of anxiety and depression among the participants (n=182)

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Table 4: Factor associated with anxiety (n=182)

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Grades of glaucoma especially advanced/blind were the most important factor that significantly (P < 0.001) affected depression. Other factors that significantly affected depression among the study population include occupation especially trading and unemployment (P < 0.01), IOP < 21 mmHg (P < 0.01) and moderate/severe/blind visual acuity (P < 0.02) [Table 5].
Table 5: Factor associated with depression (n=182)

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   Discussion Top


The participants were mainly females, married, civil servants with tertiary education, and a mean age of 59.7 ± 13.3 years. The age of the participants in this study is similar to that reported in previous studies in Nigerian,[9],[10] Ethiopia,[28] China,[29] and Karachi[30] but differs from that reported in Germany[18] with a mean age of 70.8 ± 8.4 years. This could mean that the glaucoma in Africa and Asia affects the younger age groups when compared with the Europeans. Global interventions for this emerging sight-threatening disease should, therefore, be more drawn to these continents to halt the irreversible glaucoma blindness with its associated economic loss.

In this study, 80 (44%) participants had anxiety; this prevalence is higher than those reported in previous studies (2.2%–33%).[9],[10],[13],[14],[17],[30],[31] The lower HADS cut off score used in the present study may contribute to the higher prevalence.

Seventy-six (41.8%) participants had depression; this agrees with values reported in previous studies in Asia[9],[10],[13],[31] but higher than that reported in the United States.[12] The similarity between the demographic characteristics of the participants in this study with those in the Asian studies may contribute to the similar prevalence observed. The disparity between the prevalence of depression in our study population and that reported in the United States could be due to the study definitions and instruments used in these previous studies. Glaucoma severity has been associated with depression and anxiety.[18],[19],[20] The fact that majority of the participants in the present study had advanced stage of the disease may explain this observation. Nevertheless, exploration of depression and anxiety symptoms during routine clinical evaluation of glaucoma patients is advised. These symptoms should be properly addressed to ensure and promote effective communication between clinicians and patients and treatment adherence, the hallmark of a successful glaucoma management.

In this study, reduced visual acuity and severe/blind stage of glaucoma strongly associated with anxiety and depression in the study population. Severe glaucoma with reduced visual acuity limits patients' daily life activities which may negatively affect the general as well as mental health status of patients. Previous studies in Canada,[18] Germany,[19] Singapore,[31] and India[20] have reported association between glaucoma severity and anxiety and depression though these studies did not explore its psychological impact on the patients. In contrast, a previous study by Zhou et al.[17] reported gender, age duration of the disease, and economic burden as strong factors that affected anxiety and depression among Chinese glaucoma patients; these factors affected anxiety and depression in the present study but in a nonsignificant manner.

The significant association between occupation especially trading and depression could be due to fear created by the thought of losing one's sight and consequently the source of livelihood. Incorporating a psychological health approach to glaucoma care is therefore, recommended. Further studies may be required to explain the unusual and yet significant association between IOP <21 mmHg and depression.


   Conclusion Top


The prevalence of anxiety and depression among glaucoma patients in Enugu was high. Reduced visual acuity and severe/blind stage of glaucoma were the most important factors that associated with anxiety and depression in the study population. Incorporating a psychological health approach to glaucoma care may promote effective communication between clinicians and patients, create confidence, and improve treatment adherence.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Self-sponsored.

Conflicts of interest

The authors declare no real or potential conflict of interest in this work.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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