Examining DED From a Different Perspective

Dry eye disease (DED) can have a tremendous influence on the mental and social well-being of our patients, a fact that must be taken into consideration, as a holistic view of the patient is necessary in order to achieve the most successful outcomes possible. Fortunately, there has been a recent increase in the number of studies looking at these very issues to give us a better understanding of their effect. Let’s review some of the more noteworthy research.

THE DRY EYE-mental health CONNECTION

DED can be complicated to diagnose, treat, and manage successfully. Patients may not even understand what their symptoms mean until the disease becomes more serious. Not all eye care providers have the most up-to-date tools and therapies to properly treat and manage a patient’s DED. Thus, many patients end up seeking care from multiple providers until they find one who is willing and able to help them. Consequently, patients with DED often have comorbid mental health disorders, such as anxiety and depression.¹

The Tear Film & Ocular Surface Society (TFOS) sought to determine how various lifestyle factors affect DED, and after 2 years of research, it released its lifestyle report in 2023.¹ In the report is an entire section on lifestyle challenges and their effect on ocular surface disease. That section takes a close look at the association between DED and mental health disorders (eg, depression, anxiety, and post-traumatic stress disorder), coping, stress, and sleep.¹Note: More than 150 research articles were cited in this section of the TFOS lifestyle report on these topics.

Depression, Anxiety, and DED

When looking at the prevalence of depression among patients with eye disorders, a 2017 study noted that across various eye diseases, depression prevalence was found to be the highest among patients with DED, even when compared with patients with glaucoma and age-related macular degeneration.² A meta-analysis from 2021 found a depression prevalence of 40% and an anxiety prevalence of 39% in patients with DED when compared with controls.³ This meta-analysis also noted that depression and anxiety were found to be significantly correlated with DED symptoms but not signs. In fact, at least three different studies from the TFOS lifestyle report noted that DED symptoms—not signs—were associated with depression.¹ This is often what is seen in clinical practice as well. With some patients, the symptoms of DED seem to outweigh the signs.¹

The 2021 meta-analysis mentioned above also discusses the bi-directional relationship between DED and mental health. In other words, depression and anxiety can be both a cause and an effect of DED.³ In addition, a large, population-based study from the Netherlands with almost 80,000 participants noted a significant association between DED and depression even in those not taking antidepressant medication, thus suggesting DED can occur independently of antidepressant medication use.⁴ Given this information, how should we treat DED in patients with depression and/or anxiety?

No standard guidelines exist at this time, but there are a few studies in this area. One such analysis noted that patients taking omega-3 fatty acid supplements improved in their dry eye signs and symptoms but not their depression scores, suggesting that improving dry eye symptoms does not directly translate to improved depression symptoms.⁵ However, another study found that after follow-up with various treatments for dry eye, both DED and anxiety had significant improvements, suggesting a positive relationship between the two.⁶ This shows that effective DED treatment could have a positive effect on the symptoms of depression and anxiety.⁶

One particularly important study looked at the various causes of depression and anxiety in patients with DED.⁷ The major themes of their mood disorders were reflective of the care they received from the medical community, the effect the disease had on their daily life, and the effect it had on their social interactions (Table).⁷ This study is important because it shows that the way we, as medical professionals, deliver care can directly affect the outcomes of our treatment plans.

We have heard too many times that patients get frustrated when they feel no one is listening to them, their concerns are not validated or taken seriously, they have difficulty getting the correct diagnosis, and they are pushed away by other providers who tell them nothing is wrong with them. When patients are treated this way, it can increase their depression and anxiety. Eye care providers must be mindful of this and treat patients with DED with the utmost compassion and understanding while trying to create a positive connection with them. This study also highlights the increased burden of DED and how it affects patients’ lives and work patterns, as well as social interactions.⁷ It concluded that patients with DED, depression, and anxiety might need to be treated with psychological interventions to address the causes of their mental health disorders.⁷ The big takeaway here is that, in addition to increased attention and empathy from their providers, patients with DED, depression, and anxiety may need therapy and extra support from a mental health specialist in order to better manage their DED.⁷

DRY EYE AND SOCIAL WELL-BEING

The burden of DED on the social well-being and quality of life of patients can range from slightly annoying to completely devastating. A patient’s lifestyle can be totally altered by DED. Having red, irritated, watery eyes can affect a patient’s self-esteem and self-confidence, especially for women who are no longer able to wear makeup or contact lenses. Some patients are unable to participate in hobbies and activities that bring them joy because they can’t see well or drive, especially at night. They may have difficulty in the workplace because they are not able to finish tasks on time or without taking frequent breaks. DED can also be a huge financial burden, with patients sometimes spending thousands of dollars on treatments that may provide little relief.

One interesting study from 2019 used social media listening and natural language processing with publicly available social media posts to get a better understanding of the quality-of-life and social effects of DED.⁸ This study included almost 2,300 patients and showed that DED had the biggest effect on work-related activities, electronic device use, and reading and driving ability.⁸ The biggest patient concerns and key unmet needs identified were a lack of dry eye specialists, standard diagnostic procedures, effective treatment options, and awareness around DED.⁸

In the past few years, there have been an incredible number of new pharmaceutical and technological advances in the treatment of DED. Hopefully this would translate into better patient satisfaction if a similar study were conducted today. Regardless, much work remains to be done when it comes to educating eye care providers and the general public about DED.

A more recent study looking at how DED affects quality of life surveyed more than 2,000 participants and revealed that 75% of patients find dry eye extremely or very bothersome. Specifically, 81% of patients were constantly aware of how their eyes feel and 67% of patients had to give up or cut back on something they enjoy, including screen time, time outside, and wearing makeup.⁹ These are large numbers, indicating that DED has an enormous effect on patient quality of life. This study also noted that patients with DED reported their symptoms had the biggest effect on their reading (45%), device use (35%), and driving (31%).⁹ These findings are similar to those of the study mentioned above that employed social media listening and natural language processing to better understand the effects of DED.⁸

BE KIND, BE KNOWLEDGEABLE

Research shows a strong link between patients with DED and mental health disorders, such as depression and anxiety. The associations are most likely bi-directional, and effective DED treatments may have a positive effect on a patient’s mental health. Thus, eye care providers should make sure they extend compassion to patients, take the time to determine the correct diagnosis, and stay informed of the latest treatment advances in this area.

Additionally, referral to a mental health professional may be helpful for some patients with DED, as the condition can take a tremendous toll on a patient’s social well-being. Be sure to take these factors into consideration when developing an effective treatment and management plan for this population. As always, we must continue to educate ourselves in these areas in order to improve patient outcomes, satisfaction, and quality of life.