October 2012




Managing fear and depression in glaucoma patients

by Vanessa Caceres EyeWorld Contributing Writer


The glaucoma specialist's role in helping patients cope

Depressive symptoms and anxiety are two common, normal responses to a glaucoma diagnosis. However, are glaucoma specialists addressing those fears adequately enough in newly diagnosed patients? "How do you talk to people about an incurable, blinding disease? I think this is a fundamental problem," said Reay Brown, M.D., glaucoma specialist, Atlanta Ophthalmology Associates, Atlanta. Dr. Brown, who has given talks on the topic of allaying patients' fears about a glaucoma diagnosis, believes this is an area where ophthalmologists can try a little harder. "We sometimes create depression and anxiety where there need not be. If you make the patient depressed, it's a failure in communication," he said.

Ophthalmologists might naturally think that issues of anxiety and depression connected to a glaucoma diagnosis should be addressed by a mental health specialist. "We tend to focus on the medical diagnosis and put everything else on the side. We're not trained in that area, and we're busy," said Malik Y. Kahook, M.D., professor, Department of Ophthalmology, University of Colorado, Aurora.

Plus, medical school doesn't usually discuss the soft skill of how to talk to patients. On the patient's end, the internet will often give inaccurate disease information or take facts out of context.

Still, depressed, anxious, or cognitively impaired patients are less likely to adhere to their medication regimen, putting themselves at an even greater risk for complications, Dr. Kahook said.

Additionally, you want to quell patients' sometimes irrational fears about the disease. "Anecdotally, I find patients are not depressed but anxious," said Douglas J. Rhee, M.D., assistant professor, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston. "They're afraid of going blind, and this is a relatively asymptomatic disease. It's like waiting to be punched."

What the studies show

Studies that have examined rates of depression and anxiety in glaucoma patients have mixed results. "A few studies have shown that depression is higher in these patients, but they generally show depression rates are not higher," Dr. Rhee said. "On anxiety, the results are more 50/50. We don't know enough about this issue yet."

In his recent work with Dr. Kahook, Brian Yochim, Ph.D., VA Palo Alto Health Care System and Stanford University, Palo Alto, Calif., said the investigators identified a 2006 study published in General Hospital Psychiatry that reported patients with pseudoexfoliative glaucoma had a higher rate of depressive symptoms than control participants. However, a 2002 study from Ophthalmology found the prevalence of depression to be similar when comparing open-angle glaucoma patients and controls.

The recent study from Drs. Kahook and Yochim, published in the April/May issue of the Journal of Glaucoma, tracked depression, anxiety, and cognitive impairment in older patients with glaucoma. Using a sample of 41 glaucoma patients, they found memory impairment in 20% of the sample and impaired executive functioning in 22%. They also found mild to moderate depression symptoms in 12.2% of the participants. Only one patient had significant anxiety.

"A depressed patient is less likely to understand instructions or adhere to the regimen. Anxiety and depression get in the way," Dr. Kahook said.

"The study demonstrates the importance of screening for depression and memory impairment in older adults and referring to mental health professionals for appropriate evaluation and intervention," Dr. Yochim said.

Dr. Yochim is currently researching better ways to assess cognitive functioning and symptoms of dementia in older adults with visual impairment. He said it is not yet clear if the results shown in the recently published study are limited to glaucoma or if they can be generalized to other causes of vision loss or other medical problems.

Another recent study, published in the April issue of Investigative Ophthalmology and Visual Science and led by M.L. Popescu, examined the connection between depression and glaucoma, age-related macular degeneration, and Fuchs' corneal dystrophy, all of which are associated with age progression. The researchers found that 25% of the 315 patients studied met the study's criteria for depression. "Life space and limited activities due to a fear of falling appeared to mediate the relationship between eye disease and depression," wrote the investigators.

8 ways to help patients cope

There are ways that ophthalmologists can help patients decrease depressive symptoms or anxiety. It all begins with setting the right tone when speaking with patients, Dr. Brown said.

1. Choose your words carefully, and deliver a positive message when possible. "Our words are part of the treatment," he said. Although Dr. Brown obviously acknowledges that glaucoma can be a blinding disease, he also will emphasize that with the right compliance, the prognosis is usually good and that there are many promising treatments for the future. "I tell them that if they take their drops every day, it's a reminder that this is a blinding, incurable diseasebut that's it probably not going to be blinding for them," he said. By delivering a message of hopeone that is truthful but not bleakyou will help patients cope, Dr. Brown said. When Dr. Rhee observes patients becoming anxious, he has a piece of advice. "I'll tell them that to the best of my knowledge, fear and anxiety have never cured a human disease. It's normal to go through the grieving stages, but fixating doesn't help," he said.

2. Control your own anxiety about the disease. "We sometimes betray our own anxiety and pass it back to the patients," Dr. Brown said. He likens it to parenting, when a mother's or father's fear about something is sometimes transmitted onto the children, making them feel anxious. Instead, remember that you have the power to help patients cope better by sticking with matter-of-fact but still hopeful facts about their glaucoma. 3. Tell patients that controlling glaucoma is a team effortand that they are part of that teamwork. "The patients' job is to adhere to their regimen so there is less likelihood a functional loss," Dr. Kahook said. By emphasizing this, you give patients a sense of control over the disease. Additionally, explain to patients that physicians, patients, residents and fellows, and technicians work together to help control the disease.

4. Acknowledge when things are going well. When the disease has not progressed, Dr. Brown will say so. He will also praise patients for consistently taking their medications. The positive reinforcement helps to counteract the negative news that is often part of the glaucoma patient's visits.

5. Set the tone for your staff to stay positive. "It's a self-reinforcing thing," Dr. Brown said. "If you're negative, your staff will be negative. You have to provide the momentum for them."

6. Find ways to give patients a sense of control. Education helps give patients a sense of control, which will lessen depression and anxiety, Dr. Kahook said. He is currently involved in research measuring adherence in glaucoma patients who have received more detailed education about their disease.

For the methodical engineer type patients, Dr. Rhee gives them "homework," encouraging them to monitor their IOP. Of course, more nervous patients might become too obsessive if they are constantly monitoring IOP fluctuations.

7. Refer patients to mental health professionals when necessary. Sometimes a glaucoma diagnosis will push a patient prone to anxiety over the edge, Dr. Rhee said. "I think the lack of ability to self-monitor adds to anxiety," he said. Although it's a difficult topic to discuss, Dr. Rhee recommends the help of a mental health professional to patients who are severely anxious. "Fifty percent of them are very offended, but often a family member involved will agree with the recommendation," he said. 8. Encourage patience in patients. Dr. Rhee tells patients to have some patience with themselves and the disease. "I try to impress on them that we have to take this day by day," Dr. Rhee said.

Editors' note: Dr. Kahook has financial interests with Alcon (Fort Worth, Texas), Allergan (Irvine, Calif.), Merck (Whitehouse Station, N.J.), Bausch + Lomb (Rochester, N.Y.), Glaukos (Laguna Hills, Calif.), Ivantis (Irvine, Calif.), Genentech (San Francisco), Regeneron (Tarrytown, N.Y.), Shape Ophthalmics (Boulder, Colo.), ShapeTech (San Carlos, Calif.), and Innovative Laser Solutions (Minneapolis). The other physicians have no financial interests related to this article.

Contact information

Brown: 404-252-1194, reaymary@comast.net
Kahook: 720-848-2500, malik.kahook@gmail.com
Rhee: 617-573-3670, dougrhee@aol.com
Yochim: 650-493-5000, Brian.Yochim@va.gov

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