Association between Depression And Dry eye

Association between Depression And Dry eye

Sang Beom Han, MD,1 Joon Young Hyon, MD,1 Young Joo Shin, MD,1

Won Ryang Wee, MD,2 Jin Hak Lee, MD,1

1 Department of Ophthalmology, Seoul National University Bundang Hospital, Seongnam, Korea2 Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea

Financial Disclosure: None

BackgroundBackground

As in other diseases, dry eye symptom can possibly be affected by the psychological factors, such as, depression and stress, and anxiety.

It has also been suggested that the sicca symptoms in patients with dry eye and mouth syndrome may be of psychosomatic origin.

The discrepancy between dry eye signs and symptoms also suggests the influence of psychologic factor on the perception of ocular dryness.

However, there is few reports about the relationship between dry eye and depression, whereas many previous studies have shown that depressive mood can be an important causes of oral sicca symptom.

Mariette et al. Rheumatology 2003;42:914-915

Lin et al. Invest Ophthalmol Vis Sci 2005;46:1593-1598

Anttila et al. Psychosom Med 1998;60:215-218Bergdahl et al. J Dent Res 2000;79:1652-1658

PurposePurpose

To determine the association between depressive mood and dry eye in elderly Korean population.

Material and MethodsMaterial and Methods

As a part of the Yongin Aging Study (YAS) YAS

• population-based longitudinal cohort study on the memory, mood, and sensory functions of Korean elders aged 65 years or older.

• Conducted from May 2008 to February 2009 in Yongin• Among the 1,060 elderly subjects randomly selected, 657 agreed to

participate in this study.

Initial Field studyInitial Field study Evaluation for Dry Eye

• Schirmer test• Dry Eye Questionnaire (DEQ)

Allowed responses were

‘none”, ‘rarely’, ‘sometimes’,

and ‘often or all the time’. Dry eye was defined as having one or more symptoms often or all the time.

Psychologic evaluation • Cognitive function

Mini-Mental Status Examination in the Korean Version of the CERAD Assessment Packet (MMSE-KC), a item questionnaire to screen dementia.

• Depressive mood Korean version of the Short Geriatric Depression Scale (SGDS-K), a 15-item

questionnaire (score per item 0 or 1) developed for screening of major depression. A score of 8 as optimal cutoff score of SGDS-K.

Bae et al. J Psychosom Res 2004;57:297-305

During recent 2 weeks1.Do your eyes feel dry? 2.Do you feel gritty or sandy sensation in your eyes?3.Do your eyes ever have a burning sensation?4.Do your eyes ever feel sticky?5.Do your eyes ever feel watery or tearing?6.Are your eyes ever red?

Further Evaluation for Dry EyeFurther Evaluation for Dry Eye

Tear film breakup time (BUT) test Fluorescein stain Examination of meibomian gland dysfunction

Positive signs were defined as • Tear film BUT ≤10 seconds

• Schirmer test score ≤ 5 mm

• Fluorescein score ≥ 1

• or the presence of meibomian gland disease

In each subject, the worse eye was used for analyses.

ResultsResults

Total 657 subjects• Mean age was 72.0 ± 5.9 years (mean ± SD, range 65-95)• M : F ratio was 48.2%: 51.8% (317 : 340). • 198 (30.3%) met the diagnostic criteria for dry eye, define as

presence of ≥ 1 of the 6 dry eye symptoms.• SGDS-K questionnaire was finished in 650 participant, and 148

(22.8%) met the diagnostic criteria for major depression, define as having SGDS-K score of ≥8.

• MMSE-KC questionnaire was completed in 656.• Schimer test was done in 648 participants.• 139 subjects completed the further evaluation for dry eye.

SGDS-K and MMSE-KC scores according to the presence or absence of dry eye symptomsSGDS-K and MMSE-KC scores according to the presence or absence of dry eye symptoms

Variables

SGDS-K (for Depression) MMSE-KC (for Dementia)

NScore

(Mean ± SD)P value N

Score (Mean ± SD)

P value

Dry eye symptom Questionnaire

Question 1 Positive Negative

123527

5.15 ± 4.404.08 ± 3.98

0.015 124532

24.46 ± 4.3024.08 ± 4.87

0.383

Question 2 Positive Negative

68582

6.24 ± 4.524.05 ± 3.97

<0.001 69587

23.49 ± 4.7024.22 ± 4.77

0.228

Question 3 Positive Negative

32618

5.69 ± 4.214.21 ± 4.07

0.060 33623

24.03 ± 3.8024.15 ± 4.82

0.858

Question 4 Positive Negative

56594

6.82 ± 4.844.04 ± 3.93

<0.001 56600

24.00 ± 4.9124.16 ± 4.76

0.814

Question 5 Positive Negative

106544

5.91 ± 4.613.97 ± 3.90

<0.001 107549

23.77 ± 4.7924.22 ± 4.77

0.368

Question 6 Positive Negative

45605

6.02 ± 4.504.15 ± 4.02

0.009 45611

25.11 ± 4.3724.08 ± 4.80

0.134

Dry Eye Disease Yes No

198452

5.53 ± 4.483.73 ± 3.77

<0.001 199457

24.07 ± 4.66 24.18 ± 4.81

0.784

SGDS-K and MMSE-KC scores according to the presence or absence of dry eye signsSGDS-K and MMSE-KC scores according to the presence or absence of dry eye signs

Variables

SGDS-K MMSE-KC

NScore

(Mean ± SD)P value N

Score (Mean ± SD)

P value

Dry eye signs

Schirmer I test ≤5 mm>5mm

175467

4.06 ± 4.084.37 ± 4.08

0.400 175472

24.45 ± 4.3124.03 ± 4.90

0.297

BUT ≤10 sec>10 sec

11920

3.68 ± 3.824.30 ± 3.98

0.523 11920

25.92 ± 3.0725.25 ± 3.19

0.394

Fluorescein score≥1 =0

5089

3.96 ± 3.903.66 ± 3.82

0.665 5089

25.66 ± 2.9926.10 ± 3.27

0.437

Meibonian gland disease Present Absent

7267

3.89 ± 3.793.64 ± 3.91

0.706 7267

25.81 ± 2.8125.84 ± 3.38

0.954

Frequency of positive dry eye symptoms and signs according to the presence or absence of major depression

Frequency of positive dry eye symptoms and signs according to the presence or absence of major depression

VariablesNo (%)

P valueOdds Ratio (95% CI‡)

SGDS-K ≥ 8 SGDS-K < 8

Question 1 positive† 37 / 148 (25.0%) 86 / 502 (17.1%) 0.032 1.61 (1.04 – 2.50)

Question 2 positive 28 / 148 (18.9%) 40 / 502 (8.0%) < 0.001 2.70 (1.60 – 4.55)

Question 3 positive 12 / 148 (8.1%) 20 / 502 (4.0%) 0.042 2.13 (1.01 – 4.46)

Question 4 positive 29 / 148 (19.6%) 27 / 502 (5.4%) < 0.001 4.29 (2.45 – 7.52)

Question 5 positive 40 / 148 (27.0%) 66 / 502 (13.1%) < 0.001 2.45 (1.57 – 3.82)

Question 6 positive 16 / 148 (10.8%) 29 / 502 (5.8%) 0.034 1.98 (1.04 – 3.75)

Dry eye 66 / 148 (44.6%) 132 / 502 (26.3%) < 0.001 2.26 (1.54 – 3.30)

Schirmer I test ≤ 5 mm 37 / 147 (25.2%) 138 / 495 (27.9%) 0.517 0.87 (0.57 – 1.33)

BUT ≤10 seconds 22 / 26 (84.6%) 97 / 113 (85.8%) 0.872 0.91 (0.28 – 2.98)

Fluorescein score ≥ 1 9 / 26 (34.6%) 41 / 113 (36.3%) 0.873 0.93 (0.38 - 2.27)

Meibonian gland disease 13 / 26 (50.0%) 54 / 113 (47.8%) 0.839 0.92 (0.39 – 2.15)

* Major depression was defined as SGDS-K ≥ 8

Correlation between dry eye symptom and depressionCorrelation between dry eye symptom and depression

* One-way ANOVA, Post hoc test could not be performed because one group (positive response =6) has fewer than two cases.

†Chi-square test (linear-by-linear association)

No. of positiveresponses to DEQ

No. of Patients

SGDS-K‡ Patients with major depression

Score (Mean ± SD)

P value No. (%) P value

0 427 3.62 ± 3.65

<0.001*

74 (17.3%)

<0.001†

1 103 5.24 ± 4.57 29 (28.2%)

2 61 5.15 ± 4.33 18 (29.5%)

3 38 6.34 ± 4.78 16 (42.1%)

4 15 6.53 ± 4.63 7 (46.7%)

5 5 7.00 ± 4.53 3 (60.0% )

6 1 10.00 1 (100%)

Total 650 4.28 ± 4.08 148 (22.8%)

ConclusionConclusion

There is close relationship between dry eye symptoms and depression, while no significant association was found between depression and dry eye signs.

The present study suggests that • There may be overlapped pathophysiology between major depression and

dry eye.• Dry eye may be in part a somatization disorder.

Further studies are required to elucidate the causes leading to major depression and dry eye, and the exact mechanisms that associate the two conditions.