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Depression, Anxiety, and Disturbed Sleep in Glaucoma
Agorastos Agorastos, M.D.; Christos Skevas, M.D.; Mario Matthaei, M.D.; Christian Otte, M.D.; Maren Klemm, M.D.; Gisbert Richard, M.D.; Christian G. Huber, M.D.
The Journal of Neuropsychiatry and Clinical Neurosciences 2013;25:205-213. doi:10.1176/appi.neuropsych.12020030
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Previous Presentation: Poster Session, European Psychiatric Association (EPA) Annual Meeting, 2010, Munich, Germany.

Drs. Agorastos and Skevas are equal contributors to this article.

From the Dept. of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine (AA, CO, CGH) and the Dept. of Ophthalmology, Centre for Clinical Neurosciences (CS, MM, MK, GR), University Medical Centre Hamburg–Eppendorf, Hamburg, Germany.

Send correspondence to Dr. Agorastos, Dept. of Psychiatry and Psychotherapy, Centre for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf; e-mail: aagorast@uke.uni-hamburg.de

Copyright © 2013 American Psychiatric Association

Received February 10, 2012; Revised August 16, 2012; Accepted August 30, 2012.

Abstract

Although it has been suggested that glaucoma is associated with circadian misalignment, sleep disorder, anxiety, and depression, these comorbid conditions have not received much attention. This study provides evidence for a significantly higher prevalence of depression, trait anxiety, and sleep disturbances in patients with progressed glaucoma, as compared with glaucoma patients with no or minor visual field defects (VFD). Logistic-regression analyses suggest that severe VFD constitute a significant predictor of depression, trait-anxiety, and sleep disturbance. Results indicate the necessity of regular screening and psychochronobiological treatment in glaucoma patients.

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FIGURE 1. Prevalence (%) of Depression in the Two Main (Visual Field Defect [VFD] and Non-VFD Groups

Percentage of patients fulfilling criteria for clinically relevant depression: mild depression (BDI total score: 10–18): VFD group: 13 (26.5%), non-VFD group: 8 (21.6%); moderate depression (BDI total score: 19–29): VFD group: 7 (14.2%), non-VFD group: 1 (2.7%); severe depression (BDI total score: 30–63): VFD group: 2 (4.1%), non-VFD group: 0 (0%).

p=0.026 (U=689.5; z = –2.23; r=0.24).

FIGURE 2. Prevalence (%) of Sleep Disturbance in the Two Main (Visual Field Defect [VFD] and Non-VFD Groups

Percentage of patients fulfilling criteria for clinically relevant sleep disturbance (PSQI Total score >5); no sleep problems: VFD group: 12 (24.5%), non-VFD group: 20 (54%); significant sleep disturbance: VFD group: 37 (75.5%), non-VFD group: 17 (46%); p=0.005 (U=638.5; z = –2.79; r=0.30).

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TABLE 1.Sample Differences in Age, Gender, Body Mass Index (BMI), Local Application or Oral Intake of β-Blockers, and Systemic Hypertension
Table Footer Note

Values are given as mean (SD) or N (%). Univariate analyses were calculated with t-tests (age, BMI) and χ2 tests (gender, β−blockers: local, β-blockers: oral, systemic hypertension, diabetes). VFD: visual field defect.

Table Footer Note

a The main reasons for exclusion were comorbid ophthalmological or psychiatric diseases (N=23), current employment (N=22), intake of prescribed medication (e.g., antidepressants, hypnotics, antipsychotics, cortisone; N=18), unwillingness to participate (N=8), interruption of inpatient treatment (N=3), or a combination of these factors. Of the excluded patients, 11 (VFD: 8, non-VFD: 3) reported a pre-existing diagnosis of depression, the use of antidepressants, or both.

Table Footer Note

b Distribution of glaucoma types in the VFD group: primary open angle glaucoma (POAG): N=42, normal tension glaucoma (NTG): N=1, pseudoexfoliation glaucoma (PEX): N=6; n-VFD group: POAG: N=31, NTG: N=3, ocular hypertension (OHT): N=3.

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TABLE 2.Psychometric Data
Table Footer Note

Values are mean (SD) for BDI total score, PANAS–P, and PANAS–N, and median values for STAI–S, STAI–T, of psychometric scores for the VFD and non-VFD groups. Group differences were calculated by independent-group t-tests for BDI total score, PANAS–P, and PANAS–N, and Mann-Whitney U test for STAI–S, STAI–T. Exploratory analyses revealed no significant gender bias.

Table Footer Note

U=560.0; z = –2.16; r=0.24.

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TABLE 3.Quality of Sleep Assessed by the Pittsburgh Sleep Quality Index (PSQI) Subscores and Total Score
Table Footer Note

The global PSQI score is the sum of 7 component subscores, measuring subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. Mann-Whitney U tests were conducted for all PSQI subscores and PSQI Total score. All subscores were rated on a 4-point Likert scale (0: “no problem at all;” 1: “only a very slight problem;” 2: “somewhat of a problem;” 3: “a very big problem”). Exploratory analyses revealed no significant gender bias.

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a Over-the-counter medication.

Table Footer Note

b PSQI Total Score: VFD median: 8; non-VFD median: 5.

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TABLE 4.Logistic Regression for Clinically Relevant Depression, Anxiety, and Sleep Disturbance
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The full model, containing seven independent variables (age, sex, Body Mass Index, systemic hypertension, oral β-blockers, local β-blockers, and visual field disturbance [VFD]), was statistically significant in all three cases.

Table Footer Note

a The full model was statistically significant (χ2=25.2; p=0.001) and explained between 25.4% (Cox and Snell R2) and 34.7% (Nagelkerke R2) of the variance in sleep status and correctly classified 72.1% of cases.

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b The full model was statistically significant (χ2=15.1; p=0.035) and explained between 16.1% (Cox and Snell R2) and 22.8% (Nagelkerke R2) of the variance in depression and correctly classified 68.6% of cases.

Table Footer Note

c The full model was statistically significant (χ2=14.3; p=0.046) and explained between 15.3% (Cox and Snell R2) and 23.9% (Nagelkerke R2) of the variance in trait anxiety and correctly classified 80.2% of cases.

Table Footer Note

SE: standard error; Stand. β: standardized beta; CI: confidence interval; OR: odds ratio.

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