Psychiatric–Medical ComorbidityDepression and anxiety in patients with pseudoexfoliative glaucoma
Introduction
Glaucoma is a chronic and progressive disease that is more prevalent among the elderly. Despite treatment, many patients continue to worsen and some lose vision [1]. Studies have shown that glaucoma is the second-leading cause of blindness in the United States as well as the second-leading cause of bilateral blindness in the world [2], [3]. The number of people in the United States with primary open-angle glaucoma (POAG) in the year 2000 was estimated to be 2.47 million, of whom 1.84 million were White Americans and 619,000 were African Americans [4].
The pseudoexfoliative (PX) syndrome is an age-related disorder of the extracellular matrix characterized by the production and progressive accumulation of a fibrillar material in ocular tissues and the connective tissue sections of various visceral organs [5]. Overall, it is the most common identifiable cause of glaucoma, accounting for the majority of the cases in some countries [6]. PX glaucoma (PXG) is a special subgroup of POAG associated with the PX syndrome.
Many studies have suggested an association between the PX syndrome and vascular diseases [7], [8], [9], [10], [11]. An association of exfoliative syndrome with branch and central retinal vein occlusion has been suggested [7], [8]. In the Blue Mountain Eye Study, the exfoliation syndrome correlated positively with a history of hypertension, angina, myocardial infarction or stroke [9]. In addition, some studies have reported a higher frequency of exfoliation syndrome in patients with abdominal aortic aneurysm and transient ischemic attacks [10], [11].
Previous studies investigated the extent of psychosomatic complaints in patients with glaucoma. Although several studies did not find any disturbance, most studies showed increased emotional instability, nervousness, hypochondriasis, perfectionism, decreased functional status and increased depression in different types of glaucoma [1], [12], [13], [14], [15], [16], [17], [18].
The term ‘vascular depression’ was proposed by Alexopoulos et al. [19], who suggested that it should cover a range of late-life depressive syndromes due to a variety of potential vascular mechanisms. Recently, Thomas et al. [20] have described the relationship of depression to vascular disease but did not examine the association between glaucoma and depression. To the best of our knowledge, there are no published studies on the association of PXG with depression and anxiety. Wilson et al. [1] have evaluated depression in patients with POAG and in those suspected to have glaucoma but have not separated the PXG patients from the POAG patients.
Since there is a relationship between vascular diseases and PXG, it can reasonably be hypothesized that PXG patients may have an increased prevalence of depression and anxiety disorders. This study aimed to determine whether patients with PXG are more depressed and anxious than controls.
Section snippets
Method
This clinical study was performed between December 1, 2003, and December 1, 2005, at the Departments of Ophthalmology and Psychiatry of the Gaziosmanpasa University School of Medicine. One hundred thirteen nonconsecutive subjects were enrolled in a cross-sectional, case–control, single-blind, preliminary pilot study. Forty-one patients with PXG (29 females and 12 males), 32 patients with POAG (24 females and 8 males), and 40 controls (28 females and 12 males) underwent a bilateral
Psychiatric evaluation
Following the ophthalmologist's examination, all cases were evaluated by a psychiatrist on the basis of the Structured Clinical Interview for DSM-IV (SCID-I) [22], Turkish version [23]. The scales used in the study were the Hamilton Depression Rating Scale (HDRS; 17 items) [24], Hamilton Anxiety Rating Scale (HARS) [25], Mini Mental State Examination (MMSE) [26] and Montgomery–Asberg Depression Rating Scale (MADRS) [27], which have all been validated in Turkish population studies [28], [29],
Statistical analysis
We analyzed data for normal distribution using the Shapiro–Wilk test. Statistical analyses performed for continuous variables between the groups were ‘t test for independent samples,’ analysis of variance (ANOVA) and Kruskal–Wallis ANOVA. The Mann–Whitney U test was applied for data that were not normally distributed. We used mean±S.D. notation for variables. The chi-square test was applied for discrete variables while the simple correlation analysis (Pearson correlation coefficient) was used
Results
The ages of the PXG and POAG patients and the control group were between 30 and 80 years (means±S.D., 53.26±13.22, 49.65±11.11 and 52.52±8.76 years, respectively), and all had at least a primary school education. Sociodemographic and ophthalmologic data are listed in Table 1, Table 2. Age, sex, education, income and marital status were comparable between the PXG, POAG and control groups (Table 1). There was no correlation between the HDRS, MADRS or HARS scores and the demographic parameters (p
Discussion
We have not come across another study that has investigated the frequency of psychiatric disorders in glaucoma patients using the SCID-I [31]. We preferred to use the SCID-I for psychiatric assessment because of its interuser reliability. We chose to use the HDRS and HARS as they are the best-known survey instruments for identifying symptoms of depression and anxiety. We used the MADRS as it is widely used as a rating scale in patients with physical disease [32].
Our results indicate that PXG
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