Psychological Aspects and Depression in Patients with Retinitis Pigmentosa

Incidence and Risk of Depressive Disorder in Patients With Retinitis Pigmentosa

Importance

There is a lack of large-scale clinical studies exploring mental health among patients with retinitis pigmentosa (RP). Additionally, few studies have evaluated the associations of visual impairment with mental health in young patients.

Objective

To investigate the association between depressive disorder and RP.

Design, Setting, and Participants

This was a retrospective, nationwide, population-based cohort study using data obtained from the Health Insurance Review and Assessment service in Korea between 2008 and 2022. A total of 10 879 individuals who were newly diagnosed with RP between January 2011 and December 2021, as verified by both the RP registration code (National Registry of Rare and Intractable Disease in Korea code V209) and diagnostic code (International Statistical Classification of Diseases, 10th Revision code H35.51), were included. Data analysis was performed from October 2023 to January 2024.

Exposure

Diagnosis of RP.

Main Outcomes and Measures

Participants were categorized into 3 groups based on age at diagnosis (<20, 20-39, and ≥40 years). The incidence of depressive disorder in RP was determined after excluding those diagnosed with depressive disorder prior to RP diagnosis. Age- and sex-adjusted standardized incidence ratios (SIRs) of depressive disorder in patients with RP compared with the general population were calculated. Subgroup analyses by sex and age group were conducted.

Results

A total of 10 879 patients (638 aged <20 years, 2233 aged 20-39 years, and 8008 aged ≥40 years; 5710 [52.5%] female) newly diagnosed with RP between 2011 and 2021 were included. The 10-year cumulative incidence of depressive disorder was 17.67% (95% CI, 16.57%-18.84%) in patients with RP. Subgroup analysis showed higher incidence of depressive disorder in female patients (hazard ratio [HR], 1.46; 95% CI, 1.29-1.65; P < .001) and those aged 40 years or older (HR, 1.93; 95% CI, 1.63-2.29; P < .001). The overall SIR of depressive disorder in patients with RP was 1.19 (95% CI, 1.12-1.27; P < .001), indicating a higher risk of depressive disorder compared with that in the general population. Both male and female patients with RP showed increased incidence rates of depressive disorder (17.53 [95% CI, 15.91-19.27] and 25.57 [95% CI, 23.58-27.67] per 1000 person-years, respectively) and increased SIRs of depressive disorder (1.21 [95% CI, 1.10-1.33] and 1.18 [95% CI, 1.09-1.28], respectively) (all P < .001) compared with the general population. Subgroup analysis by age group showed that the SIR peaked in patients in their 20s (1.50; 95% CI, 1.17-1.90; P = .006) and aged 60 years or older (1.25; 95% CI, 1.14-1.37; P < .001).

Conclusions and Relevance

Individuals diagnosed with RP had a higher risk of developing depressive disorder. These findings support consideration of providing emotional and social support to patients with RP.

The impact of low vision on social function: The potential importance of lost visual social cues

Visual cues usually play a vital role in social interaction. As well as being the primary cue for identifying other people, visual cues also provide crucial non-verbal social information via both facial expressions and body language. One consequence of vision loss is the need to rely on non-visual cues during social interaction. Although verbal cues can carry a significant amount of information, this information is often not available to an untrained listener. Here, we review the current literature examining potential ways that the loss of social information due to vision loss might impact social functioning. A large number of studies suggest that low vision and blindness is a risk factor for anxiety and depression. This relationship has been attributed to multiple factors, including anxiety about disease progression, and impairments to quality of life that include difficulties reading, and a lack of access to work and social activities. However, our review suggests a potential additional contributing factor to reduced quality of life that has been hitherto overlooked: blindness may make it more difficult to effectively engage in social interactions, due to a loss of visual information. The current literature suggests it might be worth considering training in voice discrimination and/or recognition when carrying out rehabilitative training in late blind individuals.

Mingmu Xiaoyao granules regulate the PI3K/Akt/mTOR signaling pathway to reduce anxiety and depression and reverse retinal abnormalities in rats

Objective: To investigate the effects of Mingmu Xiaoyao granules (MMXY) on the morphology and function of the retina and the mechanism of PI3K/Akt/mTOR pathway-related proteins in rats with anxiety and depression induced by chronic unpredictable mild stress (CUMS).

Methods: Fifty-two male Sprague Dawley rats were randomly allocated to either a control (n = 14) or a simulated CUMS group (n = 38). The CUMS model was established successfully at 4 weeks. Six rats in each group were randomly selected to be sacrificed and their retinas isolated for histological examination. At 5 weeks, rats in the CUMS group were randomly allocated to the following groups: Model (CUMS + pure water), MMXY-H (CUMS + MMXY 7.2 g/kg/d), MMXY-L (CUMS + MMXY 3.6 g/kg/d), and CBZ (CUMS + Carbamazepine 20 mg/kg/d), with eight rats in each group. All rats were given the relevant intervention once a day. At 12 weeks, sucrose preference and open field tests were performed to evaluate the anxiety and depression status of rats. In live rats, optical coherence tomography angiography was used to measure retinal thickness and blood flow, while electroretinograms (ERGs) and visual evoked potentials (VEPs) were used to evaluate retinal function. The next day, the specimens were sacrificed for serological, histological, immunofluorescence, Western blot and transmission electron microscopy examinations to explore the mechanism of MMXY in CUMS rats.

Results: MMXY improved the anxiety and depression-like behavior of rats. Results of optical coherence tomography angiography showed that MMXY improved retinal inner thickness and blood flow in CUMS rats. MMXY improved the amplitude of a- and b-waves in the scotopic and photopic ERG, as well as N2 and P2 peak time and amplitude in the flash-VEP in CUMS rats. Retinal histological staining and transmission electron microscopy showed that MMXY reversed retinal morphology and ultrastructure in CUMS rats. MMXY reduced the expression of Beclin1 and LC3I/II proteins, regulated the PI3K/Akt/mTOR pathway, inhibited autophagy, and had a protective effect on the retina in CUMS rats.

Conclusion: MMXY may effectively improve retinal morphology and function as well as anxiety and depression-like behaviors in CUMS rats by regulating the PI3K/Akt/mTOR signaling pathway.

Transcorneal Electrical Stimulation Induces Long-Lasting Enhancement of Brain Functional and Directional Connectivity in Retinal Degeneration Mice

To investigate neuromodulation of functional and directional connectivity features in both visual and non-visual brain cortices after short-term and long-term retinal electrical stimulation in retinal degeneration mice. We performed spontaneous electrocorticography (ECoG) in retinal degeneration (rd) mice following prolonged transcorneal electrical stimulation (pTES) at varying currents (400, 500 and 600 μA) and different time points (transient or day 1 post-stimulation, 1-week post-stimulation and 2-weeks post-stimulation). We also set up a sham control group of rd mice which did not receive any electrical stimulation. Subsequently we analyzed alterations in cross-frequency coupling (CFC), coherence and directional connectivity of the primary visual cortex and the prefrontal cortex. It was observed that the sham control group did not display any significant changes in brain connectivity across all stages of electrical stimulation. For the stimulated groups, we observed that transient electrical stimulation of the retina did not significantly alter brain coherence and connectivity. However, for 1-week post-stimulation, we identified enhanced increase in theta-gamma CFC. Meanwhile, enhanced coherence and directional connectivity appeared predominantly in theta, alpha and beta oscillations. These alterations occurred in both visual and non-visual brain regions and were dependent on the current amplitude of stimulation. Interestingly, 2-weeks post-stimulation demonstrated long-lasting enhancement in network coherence and connectivity patterns at the level of cross-oscillatory interaction, functional connectivity and directional inter-regional communication between the primary visual cortex and prefrontal cortex. Application of electrical stimulation to the retina evidently neuromodulates brain coherence and connectivity of visual and non-visual cortices in retinal degeneration mice and the observed alterations are largely maintained. pTES holds strong possibility of modulating higher cortical functions including pathways of cognition, awareness, emotion and memory.

The Michigan Vision-Related Anxiety Questionnaire: A Psychosocial Outcomes Measure for Inherited Retinal Degenerations

OBJECTIVE

We sought to construct and validate a patient-reported outcome measure for screening and monitoring vision-related anxiety in patients with inherited retinal degenerations.

DESIGN

Item-response theory and graded response modeling to quantitatively validate questionnaire items generated from qualitative interviews and patient feedback.

METHODS

Patients at the Kellogg Eye Center (University of Michigan, Ann Arbor, Michigan, USA) with a clinical diagnosis of an inherited retinal degeneration (n = 128) participated in an interviewer-administered questionnaire. The questionnaire consisted of 166 items, 26 of which pertained to concepts of "worry" and "anxiety." The subset of vision-related anxiety questions was analyzed by a graded response model using the Cai Metropolis-Hastings Robbins-Monro algorithm in the R software mirt package. Item reduction was performed based on item fit, item information, and item discriminability. To assess test-retest variability, 25 participants completed the questionnaire a second time 4 to 16 days later.

RESULTS

The final questionnaire consisted of 14 items divided into 2 unidimensional domains: rod function anxiety and cone function anxiety. The questionnaire exhibited convergent validity with the Patient Health Questionnaire for symptoms of depression and anxiety. This vision-related anxiety questionnaire has high marginal reliability (0.81 for rod-function anxiety, 0.83 for cone-function anxiety) and exhibits minimal test-retest variability (ρ = 0.81 [0.64-0.91] for rod-function anxiety and ρ = 0.83 [0.68-0.92] for cone-function anxiety).

CONCLUSIONS

The Michigan Vision-Related Anxiety Questionnaire is a psychometrically validated 14-item patient-reported outcome measure to be used as a psychosocial screening and monitoring tool for patients with inherited retinal degenerations. It can be used in therapeutic clinical trials for measuring the benefit of an investigational therapy on a patient's vision-related anxiety.

Anxiety and Depression in Patients With Retinitis Pigmentosa

PURPOSE

Retinitis pigmentosa (RP) is a chronic progressive disease with no curative treatments. Understanding the variables involved with improving patients' quality of life is important in managing this population. The literature investigating the relationship of anxiety and depression with RP relies on the analysis of smaller subset populations of patients with RP, and no study has quantified the effect size of the potential association. This study aims to elucidate and quantify the association between RP, anxiety, and depression.

METHODS

A retrospective case-control study was conducted of 6 093 833 medical records within the University of North Carolina Hospital and outpatient clinic system from July 1, 2004, to August 30, 2019. Patients with a diagnosis of RP, anxiety, and depression were identified within the Carolina Data Warehouse for Health by International Classification of Diseases, Ninth and Tenth Revision codes.

RESULTS

From the base population of 6 093 833 patients' medical records, 690 patients were diagnosed with RP, 253 065 with anxiety, and 232 541 with depression. Patients with RP have an odds ratio, adjusted for sex and age, of 4.915 (95% CI, 4.035-5.987) for having comorbid anxiety, 5.609 (95% CI, 4.622-6.807) for comorbid depression, and 4.130 (95% CI, 3.187-5.353) for comorbid anxiety and depression.

CONCLUSIONS

Patients with RP have a higher prevalence of anxiety and depression, with increased odds of approximately 5 to 6 times for also carrying a diagnosis of anxiety or depression and about 4 times for carrying diagnoses of anxiety and depression compared with the general population.

Quality of life of low vision patients: a systematic review and meta-analysis

OBJECTIVE

Quality of vision plays an important role in everyday living, and low vision (LV) can take a toll on individual's quality of life (QOL). The objective of this paper is to evaluate the impact of LV on QOL and depressive symptoms in LV patients compared with healthy controls.

DESIGN

Systematic review and meta-analysis.

METHODS

Literature was systematically searched to obtain all relevant records. Covidence software was used to conduct the systematic review. Duplicate records were removed, and 2 independent reviewers screened records for relevance. After screening, risk of bias assessment was carried out. Data were extracted and meta-analysis was performed using STATA 15.0. Fixed-effect and random-effect models were computed based on heterogeneity.

RESULTS

In total, 2870 records were retrieved from database and grey literature searches. Twelve articles (35 341 subjects) were included for quantitative analysis. Overall, the QOL of LV patients was significantly lower compared with healthy individuals. Common QOL questionnaires, including 25-item visual function questionnaire (VFQ-25) (standard mean difference [SMD] = 0.91, confidence interval [CI]: [0.42-1.40]), 36-item short form survey (SMD = 0.53, CI: [0.26-0.80]), VFQ-14 (SMD = 0.58, CI: [0.42-0.74]), and visual function QOL questionnaire (SMD = 0.68, CI: [0.54-0.82]), demonstrated a poor QOL in LV patients compared with healthy controls. Additionally, odds of depressive symptoms were significantly greater (odds ratio = 2.25, CI: [1.58-3.21]) in LV patients compared with controls.

CONCLUSION

LV patients demonstrated a poor QOL and higher odds of depressive symptoms compared with healthy controls.

Psychological Aspects and Depression in Patients with Symptomatic Keratoconus

Purpose

To assess the psychological status of keratoconus sufferers and to determine the relationship between depression and visual impairment in this group of patients.

Methods

Fifty-six patients with keratoconus and forty-seven age- and gender-matched healthy control subjects were retroprospectively analyzed. Every participant underwent a complete ophthalmological examination. Keratoconus diagnosis was confirmed with corneal topography and tomography. Zung Depression Inventory Questionnaire and Patient Health Questionnaire-9 (PHQ-9) were completed by everyone.

Results

Visual acuity (logMAR 0.53 ±0.30 versus 0.11 ± 0.16), PHQ-9 score (10.20 ± 4.00 versus 5.40 ± 5.01), and Zung score (46.52 ± 8.70 versus 38.53 ± 8.41) showed a statistically significant difference between keratoconus patients and healthy controls (p < 0.001 for all). Worse visual acuity was strongly correlated with older individuals (rho = 0.339, p=0.011) and higher PHQ-9 (rho = 0.765, p < 0.001) and Zung score (rho = 0.672, p < 0.001).

Conclusion

Depressive disorders appear to be directly associated with keratoconus, both in frequency and intensity. Worse visual acuity and older age could be identified as predictive factors for their emotional status. Moreover, the disease itself could be recognized as an independent risk factor for depression development, underlying the need for close monitoring and supportive management. To the best of our knowledge, our study is the first in the literature to elaborate the association between keratoconus and depression, by assessing two different questionnaires simultaneously.

Quantitative analyses of factors related to anxiety and depression in patients with retinitis pigmentosa

The purpose of this study is to determine the factors related to anxiety and depression in patients with retinitis pigmentosa (RP). The status of anxiety and depression was determined in RP patients with the Hospital Anxiety and Depression Scale (HADS) questionnaire which consisted of subscales for HADS-anxiety (HADS-A) and HADS-depression (HADS-D). The vision-specific quality of life (VSQOL) was assessed with the National Eye Institute Visual Function Questionnaire 25 (NEI-VFQ25). The correlations between the HADS-A or HADS-D scores and vision-related clinical parameters such as the best-corrected visual acuity (BCVA), Functional Acuity Score, Functional Field Score, Functional Vision Score, the NEI- VFQ25 subscale score were determined. The socioeconomic status, such as the work status and membership in the RP society, was investigated to determine the factors related to the HADS-A and HADS-D scores. One hundred and twelve RP patients (46 men and 66 women) with mean age of 60.7±15.4 (standard deviation) years were studied. The HADS-A score was not significantly correlated with any visual functions but was significantly correlated with the general health condition (r = -0.34, P<0.001) and the role limitation (r = -0.20, P = 0.03) of the NEI-VFQ25 subscale. The HADS-D score was significantly correlated with all the visual functions (r = -0.38 to 0.29, P<0.001), the NEI-VFQ25 subscale score (r = - 0.58 to -0.33, P<0.001) by Spearman’s correlations. The HADS-A score was significantly higher in the members of the RP society than in non-members (P = 0.013). The mean HADS-D score of employed individuals was significantly lower than that of unemployed ones (P = 0.001) by the Mann-Whitney U test. The results indicate that visual function impairments and vision-related quality of life are associated with a depressive state, and the general health condition is related to anxiety in RP patients. Being employed may be strongly correlated with the degree of depression in RP patients.

Coping strategies, vision-related quality of life, and emotional health in managing retinitis pigmentosa: a survey study

BACKGROUND

Retinitis pigmentosa is a group of genetic progressive retinal dystrophies that may adversely affect daily life. Those with RP should develop adaptive coping strategies to manage their condition. This study investigates the relationship between engaging (ECS) and disengaging coping strategies (DCS), vision-related quality of life (VRQoL), and emotional health, in adults living at home with retinitis pigmentosa.

METHOD

One hundred and five participants (70 female; mean_age of 46.98, SD _age  = 13.77) completed a cross-sectional survey. The questionnaire booklet consisted of the Coping Strategies Inventory - Short Form (32 items), the National Eye Institute Visual Functioning Questionnaire 25 (25 items), Marylands Trait Depression Scale (18 items), the Warwick-Edinburgh Mental Well-being Scale (14 items), and the Subjective Happiness Scale (4 items).

RESULTS

Data was analysed with a two-block hierarchical multiple regression, with the first block controlling for the demographic data (age, sex, years since retinitis pigmentosa diagnosis, number of comorbidities, participant-perceived retinitis pigmentosa severity, and knowing RP type) and the second block consisting of primary measures (type of coping strategy, VRQoL, and Emotional Health). Type of coping strategy was found to impact psychosocial variables of VRQoL, not overall VRQoL. These psychosocial VRQoL variables had a positive association with ECS and a negative association with DCS. Emotional Health increased with ECS and decreased with DCS. There was a larger impact of DCS on VRQoL and Emotional Health compared to ECS, that is, VRQoL and Emotional Health decreased more with increasing DCS than VRQoL, and Emotional Health increased with increasing ECS.

CONCLUSION

In concordance with previous research, ECS increased with increasing VRQoL and DCS decreased with increasing VRQoL. However, the findings also indicated that DCS had a greater impact than ECS on VRQoL and Emotional Health. This suggests that diminishing DCS should be prioritised over developing ECS to positively influence VRQoL and Emotional Health. Further research should investigate the impact of reducing DCS compared to increasing ECS, and how this may influence VRQoL and Emotional Health.

Prevalence, Age at Diagnosis, Mortality, and Cause of Death in Retinitis Pigmentosa in Korea-A Nationwide Population-based Study

PURPOSE

To determine the prevalence and mortality of retinitis pigmentosa (RP) patients in Korea.

DESIGN

Population-based retrospective cohort study.

METHODS

We used data covering the 2011-2014 period from the Rare Intractable Disease (RID) registry and Health Insurance Review and Assessment (HIRA) service, which include information on all patients diagnosed with RP based on predefined diagnostic criteria. Using the HIRA-RID database, we evaluated the prevalence and age at diagnosis of RP patients across the entire Korean population. We further linked the data from Statistics Korea to the HIRA-RID database to confirm mortality and causes of death.

RESULTS

The prevalence in the total population across all ages was 11.09 per 10⁵ people, and the prevalence in those over the age of 40 was 16.16 per 10⁵ people. The age at diagnosis ranged from 0 to 95 and, on average, was 44.8. The standardized mortality ratio (SMR) was 1.56 for all ages, peaking at 2.61 in men aged 40-59, which was attributed to 6.6-fold higher suicide rates than the same age group in the general male population.

CONCLUSIONS

This is the first nationwide epidemiologic study of RP patients covering the entire population of all ages. The results suggest that the prevalence of RP in Korea is about 1 in 9000 for all ages and 1 in 6000 for those over 40 years of age. The higher mortality of RP patients than that of the general population is attributable to a high suicide rate in male RP patients of working ages, which necessitates a careful attention to their mental health.

Estimation of depression prevalence in patients with Stargardt disease using PHQ-9 and Zung scores

PURPOSE

To evaluate the psychological impact and depression prevalence in patients with Stargardt disease.

METHODS

We conducted a case-control study including 39 patients with Stargardt disease and 32 age- and sex-matched healthy controls. All participants underwent a complete ophthalmologic examination and completed the Patient Health Questionnaire-9 (PHQ-9) and the Zung Depression Inventory questionnaire. Results were analyzed using IBM SPSS 22.0 software.

RESULTS

The patient group consisted of 19 men and 20 women with mean age of 36.9 ± 5.4 years and control group of 19 men and 13 women with mean age of 42.5 ± 10.1 years. The mean values of PHQ-9 and Zung scores for patients and healthy individuals were 10.9 ± 4.9, 46.7 ± 11.1, 6.7 ± 5.4, and 41.1 ± 8.5, respectively. There were statistically significant differences between the 2 groups in PHQ-9 scores (independent samples t test: p = 0.001), but not in Zung scores (Mann-Whitney test: p = 0.053). The PHQ-9 and Zung scores appeared to be moderately but significantly correlated (Pearson coefficient 0.44, p&lt;0.0001). In addition, PHQ-9 score seems to be raised along with age, whereas both scores are low when best-corrected visual acuity is high.

CONCLUSIONS

Patients with Stargardt disease exhibited more depressive symptoms compared to healthy individuals according mainly to PHQ-9 scores. Moderate depression was significantly correlated visual function decline.