March 2009




Poor vision and suicide linked?

by Rich Daly EyeWorld Contributing Editor



Ophthalmologists urged to watch for signs of depression among patients and refer those in need

Improved treatment of both visual impairment and the factors causing poor health may potentially reduce suicide risk, according to a recent study.

The survey-based research of participants over 10 years concluded that visual impairment may be associated with an increased risk of suicide through its effect on poor health.

“There are no specific types of improved treatment of visual impairment we know for certain that may potentially reduce suicide risk,” said Byron L. Lam, M.D., professor, Bascom Palmer Eye Institute, University of Miami, Fla., and one of the study authors. “However, it is reasonable to hypothesize that reduction of visual impairment in general is likely to reduce risk of suicide.”

The findings were based on an analysis of annual crosssectional multistage area probability surveys from 1986 through 1996 of the U.S. civilian noninstitutionalized population, which were conducted by the National Center for Health Statistics. The researchers performed a mortality linkage through 2002 with the National Death Index of 137,479 of the adults surveyed. They found that during a mean follow-up of 11 years, 200 suicide deaths were reported among the study population. After controlling for survey design, age, sex, race, marital status, a number of nonocular health conditions, and self-rated health, the direct effect of visual impairment on death from suicide was elevated but not significant. However, the approximate indirect effect of visual impairment on death from suicide via either poorer self-rated health or number of nonocular health conditions was significant.

The findings were published in the July 2008 issue of the Archives of Ophthalmology and titled “Reported Visual Impairment and Risk of Suicide.”

“We were expecting to find a possible direct effect of visual impairment on suicide and were a bit surprised to find the indirect effect of visual impairment on risk of suicide,” Dr. Lam said.

Patient awareness needed

The clinical implications of the study are less clear because there are no specific types of improved treatment of visual impairment that are known to potentially reduce suicide risk, according to Dr. Lam.

“However, it is reasonable to hypothesize that reduction of visual impairment in general is likely to reduce risk of suicide,” he said.

Dr. Lam encouraged ophthalmologists to closely watch a patient’s reaction to visual loss and make prompt referral to a psychologist or psychiatrist when warranted.

Findings questioned

The finding of a link between visual impairment and suicide would be an important part of suicide prevention, given that many visual impairment cases can be improved via either appropriate treatments or assistance from low vision services, said Jie Jin Wang, Ph.D., associate professor, Centre for Vision Research, Westmead Millennium Institute, University of Sydney, Australia.

However, he doubted that such a connection had been established by the study. The visual impairment status was self reported in this study and the authors did not control for some important confounding factors, such as a history of depression and family history of depression or suicide.

“Without taking these factors into consideration, the association observed could have been due to, for example, depression, as persons who were depressed could have been more likely to report having visual impairment,” Dr. Wang said.

High confidence in an association between visual impairment and suicide will have to wait for multiple studies to show consistent and coherent evidence of it. Gerald McGwin Jr., Ph.D., professor of epidemiology, School of Medicine, University of Alabama, Birmingham, agreed that the findings were based “on shaky ground.”

The finding of a relationship appears to be a statistical phenomenon because a very high number of subjects were included in the study, which allowed the researchers to find a relatively small effect. The finding could stem from the imprecise measure of visual impairment in the National Health Interview Survey. Further research is needed to examine a cohort of individuals with more objectively quantified measures of visual impairment, Dr. McGwin said.

Dr. Lam said that additional research using specific clinical parameters such as visual acuity, contrast and glare sensitivity, stereoacuity, or visual fields would be difficult because it would require examinations or finding clinical data on tens of thousands of patients due to the low rate of suicide compared to other types of mortality.

The applicability of the study is also limited, Dr. McGwin said, because the mental health impact of vision loss is generally mitigated by the gradual nature of most vision loss. Medical professionals have ample opportunity to observe such patients because the natures of conditions that cause vision loss require regular examination.

However, Dr. McGwin agreed that eye care professionals should be aware of symptoms of depression and watch for them, regardless of a patient’s visual impairment.

Editors’ note: The physicians interviewed did not indicate any financial interests related to their comments.

Contact information

Lam: 305-326-6021,
McGwin: 205-325-8117,
Wang: 61-2-9845-5006,

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