The Hidden Burden of DED: A Biopsychosocial Perspective

Dry eye disease (DED) is increasingly recognized as a biopsychosocial condition—one that extends far beyond ocular surface discomfort. DED affects patients’ mental health, time, finances, and overall quality of life. This article reviews the physiological and psychological burdens of DED, drawing from the literature to highlight the need for a more integrated, multidisciplinary approach to care.

EFFECT ON QUALITY OF LIFE

DED significantly impairs quality of life, workplace productivity, and emotional well-being, particularly in individuals who have more severe symptoms.¹ Notably, the effect is greater on women than men.² Patients frequently face difficulties accessing appropriate care, understanding the chronicity of their condition, and finding effective treatment.

A key challenge lies in information access; up to 50% of patients report that their eye care provider is not their primary source of information on treating their DED, with 29% relying on online and social media sources.³ This can lead to misinformation, wasted time, and unnecessary financial burden—ultimately affecting patient outcomes and clinical workflow.

ECONOMIC AND TIME BURDENS

DED can be time-consuming and expensive to manage. One in four patients reports spending 1 hour each day on treatment—not including the time spent researching and sourcing products.³ Patients may spend up to $1,300 annually on artificial tears alone, which is generally considered a first line of treatment for most optometrists.³

The average cost to manage a patient with DED in the United States was estimated to be $13,302 in 2011—a figure that has likely increased in 2025 due to inflation and the growing cost of specialized therapies.⁴ More severe disease correlates with higher health care use, multiple visits, and increased out-of-pocket spending. Lack of effective monotherapies, low compliance, and fragmented care models also contribute to reduced workplace productivity.

THE BIDIRECTIONAL LINK BETWEEN DRY EYE AND MENTAL HEALTH

The relationship between DED, depression, and anxiety is bidirectional. Inflammatory processes, ocular discomfort, and side effects of systemic medication all play a role. Conversely, patients with depression often experience more severe dry eye symptoms, and vice versa.^5,6

One study proposed that depression should be considered a comorbidity of DED, as both signs and symptoms are independently associated with mood disorders.⁷ Patients with depression tend to spend longer time on devices, which can exacerbate symptoms. Furthermore, central pain desensitization—a common finding in depression—may alter how patients experience ocular discomfort.

Lack of diagnosis and inadequate treatment can lead to a worsened sense of well-being. According to one study, DED is associated with diminished mental health-related quality of life, which encompasses physical, emotional, and social functioning in relation to disease.¹ Another study involving 194 US veterans at a Veterans Affairs eye clinic found that individuals who relied on catastrophizing—a maladaptive coping mechanism marked by rumination, helplessness, and magnifying perceived problems—experienced more severe dry eye symptoms. Pain measured on the Pain Catastrophizing Scale was positively correlated with symptoms but did not necessarily correlate with signs of DED.⁸ These results underscore the role of psychological state and coping mechanisms in shaping a patient’s perception of ocular discomfort, even when clinical findings appear normal.⁸

There are biological reasons why people who catastrophize may feel more dry eye pain. Catastrophizing can raise stress hormones and inflammation, which can increase pain. It can also interfere with the brain’s ability to block pain signals, intensifying the feeling. Brain scans show that catastrophizing changes how the brain processes and reacts to pain, which may help explain why some people feel more intense dry eye symptoms, even if their eye examination looks normal.⁸ This highlights the need to incorporate mental health evaluations and promote adaptive coping strategies when managing patients with ocular pain and DED symptoms.

HOW DEPRESSION EXACERBATES DED

Antidepressant medications can induce or worsen DED, although their side effects don’t always align with symptom severity.⁷ Symptoms such as social withdrawal, fatigue, and frustration create a feedback loop: depression worsens DED, and vice versa. This reciprocal burden can deeply interfere with activities of daily living. In fact, up to 70% of patients report impairment in daily function—especially in office environments. Tasks such as reading, driving, and using digital screens are often limited, leading to social isolation and emotional distress.^9,10 Many patients begin avoiding environments that worsen their symptoms or affect their ocular appearance, reinforcing a cycle of isolation.

FUTURE DIRECTIONS

To break the cycle of isolation, we must better understand the psychological mechanisms linked to DED and advocate for interdisciplinary care. Future research should focus on the neuropsychological and inflammatory overlap between DED, depression, and anxiety.

Clinically, optometrists and ophthalmologists can consider partnering with mental health professionals, especially those trained in cognitive behavioral therapy, which has shown promise in helping patients manage chronic disease symptoms, including pain and emotional regulation.¹¹

Furthermore, public health campaigns, online support groups, and vetted educational content on social media can serve as valuable tools for patients who already turn to the internet for answers. Empowering patients with accurate, empathetic resources may reduce misinformation and increase engagement.

THE ANSWER IS INTEGRATION

DED is more than a surface-level condition—it is a multidimensional disorder that affects a patient’s time, finances, productivity, and mental health. Recognizing its biopsychosocial nature is essential to providing compassionate, evidence-based care. The future of DED management must focus on collaborative care that integrates ocular treatment with mental health support and patient-centered communication.