Topical beta-blockers are not associated with an increased risk of treatment for depression

Depression and Eye Disease-A Narrative Review of Common Underlying Pathophysiological Mechanisms and their Potential Applications

Background: Depression has been shown to be associated with eye diseases, including dry eye disease (DED), cataracts, glaucoma, age-related macular degeneration (AMD), and diabetic retinopathy (DR). This narrative review explores potential pathophysiological connections between depression and eye disease, as well as its potential correlations with ocular parameters. Methods: A literature search was conducted in August 2022 in PUBMED, EMBASE, and PsycINFO. Published articles related to the subject were consolidated and classified according to respective eye diseases and pathophysiological mechanisms. Results: The literature reviewed suggests that common pathophysiological states like inflammation and neurodegeneration may contribute to both depression and certain eye diseases, while somatic symptoms and altered physiology, such as disruptions in circadian rhythm due to eye diseases, can also influence patients' mood states. Grounded in the shared embryological, anatomical, and physiological features between the eye and the brain, depression is also correlated to changes observed in non-invasive ophthalmological imaging modalities, such as changes in the retinal nerve fibre layer and retinal microvasculature. Conclusions: There is substantial evidence of a close association between depression and eye diseases. Understanding the underlying concepts can inform further research on treatment options and monitoring of depression based on ocular parameters.

Gut microbiota compositional profile and serum metabolic phenotype in patients with primary open-angle glaucoma

The gut microbiota (GM) and its influence on host metabolism are considered to be an environmental factor that contributes to the progression of many immune and neurodegenerative diseases. However, the features of the GM and serum metabolites in Primary open-angle glaucoma (POAG) patients have not been clearly elucidated. The purpose of this research is to explore the gut microbial composition and serum metabolic phenotype in POAG patients. 16S rRNA V4 genes of bacteria from the fecal samples of 30 POAG patients and 30 healthy subjects were sequenced by the Illumina MiSeq platform and then analyzed by QIIME. Their serum samples were analyzed by gas chromatography/mass spectrometry (GC-MS)-based metabolomics. The association between gut microbial species and host circulating metabolites and clinical phenotypes was also analyzed. Compared with controls, f Prevotellaceae, g unidentified Enterobacteriaceae, and s Escherichia coli increased the most in POAG patients, whereas g Megamonas and s Bacteroides plebeius significantly decreased in POAG patients. The alteration of the endogenous metabolomic profile in POAG patients included five amino acids or dipeptides, two hormone derivates, one purine derivative, one bile acid derivative and one organic acid. It also showed that citric acid was positively correlated with Megamonas, whereas L-γ-Glutamyl-L-alanine, MHPG, cholic acid glucuronide and hypoxanthine were negatively correlated with Megamonas. Mean visual acuity was negatively correlated with Blautia, mean VF-MD was negatively correlated with Faecalibacterium, and average RNFL thickness was positively correlated with Streptococcus. Our results revealed that there was a distinct difference in GM composition and serum metabolic phenotype between POAG patients and healthy individuals. This finding suggests the potential correlations between the GM and serum metabolites in the pathogenesis of glaucoma and thus provides new insight into the GM-targeted interventions of this disease.

Trends in and Predictors of Depression Among Participants in the Collaborative Initial Glaucoma Treatment Study (CIGTS)

PURPOSE

To characterize longitudinal trends and factors predictive of depressive symptoms following glaucoma diagnosis in Collaborative Initial Glaucoma Treatment Study (CIGTS) participants.

DESIGN

Cohort study using follow-up data from a clinical trial.

METHODS

A total of 607 participants with newly diagnosed open-angle glaucoma were enrolled at 14 clinical centers in the United States from October 1993 through April 1997, randomized to treatment with medication or surgery, and followed every 6 months through 2004. The 8-item Center for Epidemiologic Studies Depression Scale (CES-D) was administered at baseline and follow-up visits. Three outcome measures were investigated: overall CES-D depression score, presence of mild or worse depression (CES-D score ≥ 7), and number of depressive symptoms endorsed.

RESULTS

The average baseline CES-D score was 2.4 (SD = 3.8), 12.5% of subjects reported symptoms associated with mild or worse depression, and 55.3% reported at least 1 depressive symptom. By 1 year posttreatment, depression measures decreased (1.5, 6.7%, and 38.4%, respectively), with modest decreases thereafter. Baseline factors predictive of mild or worse depression included worse vision-related quality of life (VRQOL) (odds ratio [OR] = 2.41), female sex (OR = 1.42), younger age (OR per 10 years younger = 1.24), and less than high school education (OR = 2.93); other outcomes showed similar results.

CONCLUSIONS

Depressive symptoms decreased considerably during the first year after treatment initiation, but were elevated in those with impaired VRQOL. Given the potential of depression to reduce treatment adherence and thus increase the risk of glaucoma progression, eye care providers should ask patients about depressive symptoms, provide reassurance when appropriate, and make referrals as necessary.

The association between glaucoma and risk of depression: a nationwide population-based cohort study

Background

Previous cross-sectional studies revealed a higher prevalence of depression among glaucoma patients. However, cohort studies were in lack to build the risk of incident depression after the diagnosis of glaucoma. The aim of our study was to investigate the association between glaucoma and the subsequent risk of developing depression and to assess risk factors associated with depression in glaucoma patients.

Methods

A population-based retrospective cohort study using the Taiwan National Health Insurance Research Database was conducted from January 1, 2001 through December 31, 2011. Glaucoma patients (n = 8777) and age- and gender-matched control subjects without glaucoma (n = 35,108) were enrolled in the study. Kaplan-Meier curves were generated to compare the cumulative hazard of subsequent depression between the glaucoma and control groups. A Cox regression analysis estimated the crude and adjusted hazard ratios (HRs) for depression. Risk factors leading to depression were investigated among the glaucoma patients.

Results

Glaucoma patients had a significantly higher cumulative hazard of depression compared to the control group (p-value < 0.0001). The Cox regression model indicated that the glaucoma group had a significantly higher risk of depression (adjusted HR = 1.71). Within the glaucoma group, significant risk factors for depression included age, female, low income, substance abuse, and living alone. However, the use of β-blocker eye drops and the number of glaucoma medications were not significant risk factors for depression.

Conclusion

Patients with glaucoma are at significantly greater risk of developing depression. Among glaucoma patients, age, female, low income, substance abuse, and living alone were significant risk factors for depression.

Assessment of Depression, Anxiety, and Quality of Life in Singaporean Patients With Glaucoma

PURPOSE

To determine the prevalence and risk factors for anxiety disorder and depression among glaucoma patients in Singapore, and to assess the relationship between quality of life (QOL) and depression/anxiety.

METHODS

In this cross-sectional study, glaucoma patients aged 21 and above with a known diagnosis of primary open-angle glaucoma or primary angle-closure glaucoma were recruited from a tertiary care hospital. Patients with other types of glaucoma, and coexisting ocular or psychiatric disorders were excluded.Ophthalmic examination was carried out on all participants, which included best-corrected visual acuity (BCVA), intraocular pressure (IOP), gonioscopy, standard automated perimetry, and optic disc evaluation. Sociodemographic information and treatment histories were also collected.The Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), and Visual Function Questionnaire (VFQ25) were administered to evaluate for depression, anxiety, and impact on QOL, respectively.

RESULTS

A total of 100 patients were included in this study. The mean age was 67.1±12.0 years (range, 24 to 90 y). The frequency of depression and anxiety among our patients was 30% and 64%, respectively. The mean HAM-D score was 4.37±4.17 (range, 0 to 17), whereas the mean HAM-A score was 2.38±2.80 (range, 0 to 13). The mean VFQ25 score was 78.8±16.0 (range, 42.4 to 97.0). The poorest subscale on the VFQ25 was driving, with a mean score of 42.4±42.6 (range, 0.0 to 100.0).We did not find any significant difference between the presence of depression/anxiety between patients with primary open-angle glaucoma (P=0.263) and primary angle-closure glaucoma (P=0.830). Risk factors for depression included: female sex (P=0.020), higher logMAR BCVA in the worse eye (P=0.004), higher cup-disc ratio (P=0.016), lower MD in the better and worse eye (P=0.022 and 0.001, respectively), and lower mean VFQ25 score (P<0.001). Risk factors for anxiety included: lower MD in the worse eye (P=0.004) and lower mean VFQ25 score (P=0.004). There was also no significant association between the use of topical β-blockers/carbonic anhydrase inhibitors with depression (P=0.793) or anxiety (P=0.282).

CONCLUSIONS

There is a relatively high prevalence of depression (30%) and anxiety disorders (64%) among glaucoma patients in Singapore. Female glaucoma patients are more likely to suffer from depression. Other risk factors for depression include higher cup-disc ratio, higher logMAR BCVA, lower MD, and a lower mean VFQ25 score. Risk factors for anxiety disorder include lower MD and lower mean VFQ25 score. Ophthalmologists could consider use of the VFQ25 as an assessment for impairments in QOL in a glaucoma patient. If a glaucoma patient is at high risk of depression or anxiety disorder, a multidisciplinary management approach involving ophthalmology and psychiatry may be required.

Psychological Aspects of Glaucoma

Glaucoma is a group of optic neuropathies that is more prevalent among the elderly population and commonly associates with comorbidities, including mental disorders in that population. This article reviews the relationship between glaucoma and mental disorders. In it, we discuss the coexistence of glaucoma and mental illnesses, including Alzheimer's disease, depression, and personality disorder. We also focus on the proper treatment approaches for glaucoma patients with mental comorbidity and poor treatment adherence. We summarize some cautiously recommended psychotherapeutic medications, while also discussing the psychologically adverse effects of antiglaucoma medications.

Association of Ophthalmologic Disorders and Depression in the Elderly: A Review of the Literature

OBJECTIVE

To review the prevalence of depression in common ophthalmologic disorders in the elderly and provide insight into treatment.

DATA SOURCES

PubMed, Google Scholar, and DynaMed were searched using the terms depression and ophthalmology in combination with depression, mood disorders, cataracts, vision loss, age-related macular degeneration, primary open-angle glaucoma, and Fuchs corneal dystrophy. Articles were limited to those published in the English language between 1993 and 2013.

STUDY SELECTION AND DATA EXTRACTION

Twenty-eight articles that studied the prevalence of depression in ophthalmologic disorders were screened and summarized.

RESULTS

The strongest association between ophthalmologic disorders and psychiatry is depression. In the future, primary care physicians and psychiatrists should play a significant role in the assessment and treatment of depression in visually impaired patients.

CONCLUSION

Greater recognition and treatment of depression in individuals with impaired vision is warranted.

Anxiety and Depression are More Prevalent in Primary Angle Closure Glaucoma Than in Primary Open-Angle Glaucoma

PURPOSE

The aim of this study was to assess the prevalence of psychological disturbances and personality traits in primary angle closure glaucoma (PACG) and primary open-angle glaucoma (POAG) patients.

METHODS

A sample of 50 PACG patients, 50 POAG patients, and 50 normal controls were enrolled in this study. All the participants were asked to complete the following questionnaires: Self-rating Anxiety Scale (SAS), Self-rating Depression Scale (SDS), Eysenck Personality Questionnaire (EPQ), and Defense Style Questionnaire (DSQ). Analysis of variance and t test were used to compare the subscores between the groups.

RESULTS

The scores of SAS and SDS were higher in glaucoma patients than in controls, whereas the PACG group had a higher score for both scales (48.44±9.90; 53.64±9.74) than the POAG group (42.62±9.00, P=0.034; 49.02±11.47, P=0.131) and control group (37.10±6.08, P=0.000; 38.86±6.64, P=0.000). Taking an SAS score of ≥45 and an SDS score of ≥50 as cut-offs, the prevalence of anxiety and depression in the PACG group (66.0%, 56.0%) was significantly higher than in the POAG group (44.0%, P=0.002; 40.0%, P=0.033) and control group (16.0%, P=0.000; 10.0%, P=0.000). The values of psychoticism and neuroticism in EPQ for the PACG and POAG groups were significantly higher than those for controls (P<0.05). In DSQ, PACG and POAG patients adopted immature and neurotic defense styles more often than controls (P<0.05). No significant differences were found between male and female participants in all the questionnaires used (P>0.05).

CONCLUSIONS

Significant differences were found between primary glaucoma patients and normal controls in psychiatric questionnaires, whereas the level of anxiety and depression was found to be significantly higher in PACG patients than in POAG patients and controls.

Risk factors for depressive symptoms in glaucoma patients: a nationwide case-control study

PURPOSE

The purpose was to investigate the risk factors for depressive symptoms in glaucoma patients.

METHODS

From the Longitudinal Health Insurance Database in Taiwan, we included 1190 glaucoma patients with subsequent depression diagnoses in the case group and randomly selected 4673 glaucoma patients without depression diagnoses as the control group, matched by age, sex, and time of glaucoma diagnosis. The age-adjusted Charlson comorbidity index (ACCI) score was used to compute the burden of comorbidity for each patient. Current use (past 6 months) of topical antiglaucoma medications and systemic medications was identified. Multivariate regression was used to analyze the risk factors for depression.

RESULTS

The mean age for glaucoma patients was 61.88 years. Patients with depressive symptoms had significantly higher ACCI scores (P < .0001). The current use of any topical antiglaucoma medications was not associated with an increased risk for depression. However, higher ACCI scores (P < .0001), cerebrovascular diseases (odds ratio [OR] = 1.324, 95 % confidence interval [CI] = 1.118--1.568), dementia (OR = 2.647, 95 % CI = 2.142-3.270), thyroid diseases (OR = 1.720, 95 % CI = 1.366-2.165), headaches (OR = 1.299, 95 % CI = 1.112-1.518), and current use of systemic β-blockers (OR = 1.782, 95 % CI = 1.538-2.065) and calcium channel blockers (OR = 1.396, 95 % CI, 1.197-1.629) were found to increase the risk of depression in glaucoma patients.

CONCLUSIONS

In this study, a comorbidity burden was a significant risk factor for depression in glaucoma patients, particularly for those currently using systemic β-blockers and calcium channel blockers.

Interactions of atenolol with alprazolam/escitalopram on anxiety, depression and oxidative stress

Anxiety and depression are highly comorbid disorders possibly sharing a common neurobiological mechanism. The dysfunction of serotoninergic, noradrenergic and dopaminergic neurotransmission, abnormal regulation in the hypothalamic-pituitary-adrenal axis (HPA), disturbance of cellular plasticity including reduced neurogenesis, or chronic inflammation connected with high oxidative damage play a crucial role in the development of anxiety and depression. The present study was aimed to investigate the effects of atenolol alone and in combination with alprazolam/escitalopram on anxiety, depression and oxidative stress. Wistar albino rats were subjected to 21 day treatment of drugs then exposed to elevated-plus maze (EPM) and modified forced swim test (MFST), and oxidative stress markers were estimated in isolated brain tissue of all groups. The results indicated that atenolol in combination with alprazolam/escitalopram exhibited antidepressant effects by significantly decreasing the immobility and increasing the swimming behavior in the MFST and anti-anxiety effects by increasing the percentage preference and number of open arm entries as well as time spent in open arm in EPM. Pretreatment with atenolol alone and combination with alprazolam/escitalopram also ameliorated tissue glutathione (GSH) and decreased malondialdehyde (MDA) level significantly which explore antioxidant properties of drugs, and combination augments the therapeutic response of monotherapy in depression. In conclusion behavioral and biological findings indicate that the combination of atenolol with alprazolam/escitalopram has the potential of being highly efficacious in treating anxiety and depressive disorders as well as oxidative stress.

Statin use and incident prostate cancer risk: does the statin brand matter? A population-based cohort study

BACKGROUND

Statins have known anticarcinogenic effects; evidence for long-term statin use as effective chemoprevention for prostate cancer is inconsistent.

METHODS

We conducted a population-based cohort study to examine the association between statin use and risk of prostate cancer using the Database of Clalit Health Services. A total of 66,741 eligible participants were identified at 1 January 2001 and followed through to 31 December 2009. Cox proportional hazard models were used to compute hazard ratios (HRs) of incident prostate cancer associated with statin therapy controling for patients' clinical and sociodemographic characteristics.

RESULTS

A total of 1813 cases of prostate cancer were diagnosed. Statin use was associated with a decreased incidence of prostate cancer, the association was stronger with increasing total dose, hydrophobic statins use and longer periods of treatment. When comparing statin use of over 6 months, this association was strongest for simvastatin (HR 0.51, 95% confidence interval (CI) 0.47-0.56), atorvostatin (HR 0.48, 95% CI 0.33-0.68) and rosuvastatin (HR 0.22, 95% CI 0.08-0.75).

CONCLUSIONS

Our findings suggest that prolonged statin use is associated with a reduced risk of prostate cancer; however, this was not true for all types of statin.

Prevalence and predictors of depression among participants with glaucoma in a nationally representative population sample

PURPOSE

To investigate the prevalence of and risk factors for depression among participants with glaucoma and the predictive value of glaucoma for depression.

DESIGN

Cross-sectional study.

METHODS

This study included 6760 participants in the National Health and Nutrition Examination Survey (NHANES) between 2005 and 2008, aged ≥40 years, who reported a presence or absence of glaucoma. Demographic and disease-related information was obtained by interview. Self-reported measures of vision were ascertained via items from the Visual Function Questionnaire (VFQ-25). Participants underwent visual acuity examination, fundus photography, and visual field testing with screening frequency-doubling technology (FDT N-30-5). The main outcome was presence of depression, as determined by a score ≥10 on the Patient Health Questionnaire-9 (PHQ-9).

RESULTS

Prevalence of depression among participants with and without glaucoma was 10.9% (SEM 2.2%) and 6.9% (SEM 0.62%), respectively. While the presence of glaucoma was significantly associated with depression after adjustment for demographic factors (OR 1.80, 95% CI 1.16-2.79), this association was not significant after adjustment for self-reported general health condition (OR 1.35, 95% CI 0.822-2.23). Among participants with glaucoma, objective measures of glaucoma severity were not significant predictors for depression. However, several self-reported measures of visual function were significantly associated with depression.

CONCLUSIONS

Glaucoma is a significant predictor of depression after adjustment for demographic factors and multiple comorbidities, but not after adjustment for self-reported general health condition. Among participants with glaucoma, self-reported measures of vision were significant risk factors for depression, whereas objective measures of vision were not.

The incentive to publish negative studies: how beta-blockers and depression got stuck in the publication cycle

OBJECTIVES

The hypothesis that use of beta-blockers causes depression has been proposed more than 40 years ago. However, despite the publication of numerous studies, the issue remains unresolved. The aim of this article is to describe a publication pattern in these studies, which may explain why the controversy persists.

STUDY DESIGN AND SETTING

A literature search was performed in Embase, Medline, and references of relevant articles. Studies that tested whether patients using beta-blockers for cardiovascular conditions had an increased risk of depression compared with nonusers were included.

RESULTS

The search yielded 22 observational studies. A specific publication pattern recurred several times in these studies. Each study that presented statistically significant findings was followed by several studies that refuted those findings. This publication cycle arose in cross-sectional studies, longitudinal studies, and meta-analyses, as well as for beta-blockers in general, propranolol, and nonselective beta-blockers. Some underpowered nonsignificant findings were published in high-impact journals.

CONCLUSION

The publication cycle clearly illustrates that significant findings are published ahead of nonsignificant findings, and that significant findings seem to provide an incentive to publish nonsignificant studies. Therefore, studies that may have correctly shown that beta-blockers increase the risk of depression will have been refuted too. Publication bias because of false nonsignificant studies may obstruct scientific progress.

A review on the putative association between beta-blockers and depression

Several kinds of systematic studies have been conducted verifying the putative association between β-blockers and depressive symptoms. However, many of these studies had important limitations in their design. In most of the studies, no effect of β-blockers on depressive symptoms was seen. Because individual susceptibility cannot be ruled out, clinicians must stay vigilant, especially with patients who have a positive personal or family history and who have been prescribed lipophilic β-blockers. However, fear for depression should not be the reason for reluctance in prescribing β-blockers to cardiovascular patients.

Use of glaucoma medications: state of the science and directions for observational research

PURPOSE

To summarize observational studies that focus on the use of glaucoma medications and to identify gaps in knowledge to guide future investigation.

DESIGN

Literature study.

METHODS

We searched the electronic databases MEDLINE, EMBASE, and PubMed for English language articles published through December 2009 using the search terms physician's practice patterns, drug prescriptions, pharmaceutical services, medication adherence, ophthalmology, glaucoma, and ophthalmic solutions. We categorized studies by areas of focus and extracted and summarized key features: study population, data sources, and main findings.

RESULTS

We identified 2224 articles by the search. Fifty-five described glaucoma medication use using large databases. Predominant areas of focus were: trends in prescription choices (n = 13); adherence, persistence, or both (n = 31); rational use of medications (n = 9); and policy-related issues (n = 2). Over the last decade, use of β-blockers and miotics has decreased substantially, whereas new agents, particularly prostaglandin analogs, have become more popular. Nonadherence was an issue in more than 25% of patients. A significant proportion of patients with comorbidities, contraindications, or both had received topical β-blockers.

CONCLUSIONS

To date, most studies have focused on adherence to glaucoma medications and changes in treatment choices. Major gaps in knowledge include prescribing patterns by prescriber specialty (ophthalmologists, primary care physicians, and optometrists), medication-related problems, and subsequent adverse health outcomes. Well-designed longitudinal observational studies addressing these gaps are warranted to improve patient safety.

High prevalence of anxiety and depression in patients with primary open-angle glaucoma

PURPOSE

To assess anxiety and depression in patients with primary open-angle glaucoma (POAG).

DESIGN

Multicenter prospective case-control study.

PARTICIPANTS

Two hundred thirty patients with POAG and 230 sex-matched and age-matched reference subjects with no chronic ocular conditions except cataracts.

INTERVENTION

Anxiety and depression were evaluated using Hospital Anxiety and Depression Scale (HADS) questionnaire, which consists of 2 subscales with ranges of 0 to 21, representing anxiety (HADS-A) and depression (HADS-D).

MAIN OUTCOME MEASURE

The prevalence of POAG patients with anxiety (a score of more than 10 on the HADS-A) or depression (a score of more than 10 on the HADS-D) was compared with that in the reference subjects. The prevalence of patients with depression was compared between the POAG patients with and without current beta-blocker eye drops.

RESULTS

The prevalence (13.0%) of POAG patients with anxiety was significantly higher (P=0.030) than in the reference subjects (7.0%). The prevalence (10.9%) of POAG patients with depression was significantly higher (P=0.026) than in the reference subjects (5.2%). Between the POAG patients with and without beta-blocker eye-drops, no significant difference (P=0.93) in the prevalence of depression was noted.

CONCLUSIONS

POAG was related to anxiety and depression. No significant relationship between the use of beta-blocker eye-drops and depression was noted.

Cardiovascular and respiratory considerations with pharmacotherapy of glaucoma and ocular hypertension

Glaucoma and ocular hypertension are highly prevalent conditions in individuals over the age of 40 and are commonly seen together in patients with cardiovascular disease. Many of the antiglaucoma medications, when systemically absorbed, affect the sympathetic and parasympathetic nervous systems of patients and can cause cardiovascular toxicity. Such adverse effects are frequently associated with the long-term use of potentially toxic agents in elderly people, who are most prone to chronic eye disease. Moreover, patients may not associate their symptoms with the topical eye medications, and consequently may not report adverse drug effects. Drug-drug interactions can also occur when patients are taking medications for both cardiovascular disease and glaucoma. In this review, the systemic toxicity of these agents is reviewed, along with possible drug-drug interactions. Mention is made of other antiglaucoma medications used alone and in combination with topical beta-blockers. Identification of genetic loci-a bold new step toward glaucoma treatment-is mentioned briefly at the end of the article.