Anxiety and Depression among Patients with Uveitis and Ocular Inflammatory Disease at a Tertiary Center in Southern Thailand: Vision-Related Quality of Life, Sociodemographics, and Clinical Characteristics Associated

Treatment Adherence Effect on the Visual Acuity of Behçet's Uveitis Patients

PURPOSE

This study aimed to explore the relationship between treatment adherence, visual acuity, quality of life (QoL), depression, and anxiety levels in individuals with Behçet's uveitis (BU).

METHODS

A total of 55 BU patients and 55 healthy controls completed sociodemographic questionnaires, the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), World Health Organization Quality of Life Questionnaire-BREF version (WHOQOL-BREF), Self-reported Questionnaire About Treatment Compliance, and the Morisky Medication Adherence Scale (MMAS). The scores obtained from these scales were analyzed to assess the relationship between treatment adherence, visual acuity, QoL, depression, and anxiety levels.

RESULTS

The results revealed that 36 (65.4%) of the 55 BU patients exhibited depressive symptoms, while 45 (81.8%) of them experienced symptoms of anxiety. Patients with BU demonstrated significantly higher BAI and BDI scores compared to the healthy control group (p < 0.001). Furthermore, the patient group reported lower mean scores across multiple domains of the WHOQOL-BREF questionnaire, including general health, psychological health, social relationships, and environment (p < 0.05). Moreover, a significant association was observed between low treatment adherence and lower values of best-corrected visual acuity (BCVA) (p < 0.05), as well as a higher frequency of uveitis attacks (p = 0.005).

CONCLUSION

Poor treatment adherence in BU patients has a negative effect on final visual acuity outcomes. Moreover, BU patients experience lower QoL and higher rates of depression and anxiety compared to the healthy control group. These findings highlight the importance of addressing treatment adherence and psychological well-being in the management of BU.

Psychosocial Well-Being and Quality of Life in Uveitis: A Review

PURPOSE

As a potentially sight-threatening disease with ocular, systemic, and treatment-related complications, uveitis diminishes quality of life (QOL) and affects psychosocial well-being. This review summarizes the existing tools for evaluating psychosocial well-being and/or QOL in patients with uveitis, explores the biological and non-biological factors affecting psychosocial well-being and/or QOL, and proposes future directions for incorporating these tools into clinical practice.

METHODS

A systematic search of the MEDLINE, Embase, and Cochrane databases from inception to June 8, 2022 was conducted, screening for articles focused on psychosocial well-being and/or QOL in patients with uveitis. Both quantitative and qualitative analyses were performed.

RESULTS

In uveitis research, the most frequently studied patient-reported outcome measures were vision-related QOL (e.g. Visual Function Questionnaire [VFQ-25]) and health-related QOL (e.g. Short Form Survey [SF-36]), followed by mental health indicators including depression and anxiety. Instruments have also been developed specific to the pediatric population (e.g. Effects of Youngsters' Eyesight on Quality of Life [EYE-Q]). Generally, studies report worse psychosocial outcomes and QOL in patients with uveitis compared to the general population. Contributory factors include both clinical (e.g. visual impairment, ocular comorbidities) and patient-related (e.g. older age, female sex) factors.

CONCLUSION

Given the heterogeneity of instruments used, it is worth considering standardization across large uveitis studies and trials. Beyond research, given the biopsychosocial effects on patients with uveitis, there are benefits to incorporating QOL and psychosocial assessments into clinical practice. Simplification of questionnaires into abridged forms, focusing on the most clinically relevant aspects of patient care, may be considered.

Anxiety and depression in patients with uveitis: a comprehensive review of observational studies

PURPOSE OF THE REVIEW

The purpose of this review is to provide a comprehensive summary of observational studies evaluating anxiety and depression in patients with uveitis.

RECENT FINDINGS

A higher prevalence of depression was reported in patients with uveitis compared to healthy controls in most observational studies. Symptoms of anxiety were often, but not always, significantly worse in patients with uveitis compared to controls. Most studies found that patients with uveitis had reduced vision-related quality of life that was associated with anxiety and depression symptoms.

SUMMARY

Patients with uveitis have a higher risk of experiencing symptoms of depression and could benefit from screening and treatment. Preliminary screening for vision-related quality of life could also help determine if the patient requires assistance in mental health or other aspects of daily living.

A review of patient-reported outcome measures used in uveitis

We review patient-reported outcome measures (PROMs) used to evaluate the quality of life (QoL) in uveitis and provide a quality assessment of the psychometric properties of the PROMs, making it easier to choose the best questionnaire for uveitis. Our review included 158 articles. A total of 98 PROMs were used to measure QoL in uveitis and the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ -25) was the most frequently used PROM in these studies. There were 5 uveitis-specific PROMs, but they were meant for either birdshot choroidopathy or cytomegalovirus retinitis or paediatric uveitis. There are no PROMs developed explicitly for the more common, anterior uveitis, intermediate uveitis, panuveitis, and chronic uveitis. The uveitis-specific PROMs performed better in our quality assessment criteria compared to other PROMs. However, these PROMs were constructed using traditional classical test theory and have not been assessed using the modern family of psychometric assessment methods such as Rasch analysis. As new therapeutic modalities for uveitis such as the new biological agents and steroid implants, continue to evolve, a comprehensive PROM will be increasingly valued in clinical trial settings to compare the effects of treatments from the patient's perspective.

Stress Suppresses Systemic Th17/Treg Imbalance in Rats with Experimental Autoimmune Uveitis

PURPOSE

To explore the effect of chronic unpredictable mild stress (CUMS) on the immune response involved in rats with experimental autoimmune uveitis (EAU).

METHODS

Lewis rats were randomly divided into control, EAU, CUMS, and EAU+CUMS groups and received relevant treatments. On days 7, 11, 14, 21 and 28, frequencies of Th17 and Treg cells and the related cytokines were analyzed.

RESULTS

The intraocular inflammation of EAU rats peaked between days 11 and 13, while the severity of inflammation of the rats in EAU+CUMS group fluctuated between 11 and 15 days. Both frequencies of Th17, Treg cells and the related cytokines exhibited a significant difference between the two groups on days 11 and 14.

CONCLUSION

CUMS may protect against the possible harmful effects of immune disorder in rats with EAU through suppressing the immune disorder of T lymphocyte and the related cytokine responses.

Risk of anxiety and depression in patients with uveitis: a Meta-analysis

AIM

To quantitatively evaluate the risk of anxiety and depression in patients with uveitis via performing a Meta-analysis.

METHODS

Three electronic database (PubMed, Embase, and Cochrane Library databases) were searched for studies recording data about uveitis and anxiety as well as depression simultaneously up to January 2021. The incidence rate and standard mean difference (SMD) with a 95% confidence interval (95%CI) were calculated to analyse the association using random-effects models based on heterogeneity tests.

RESULTS

In total, 12 observational studies containing 874 patients with uveitis were included. The results showed that there was a significant association between uveitis and anxiety (SMD=0.97, 95%CI: 0.39 to 1.54, P=0.0009) and depression (SMD=0.79, 95%CI: 0.51 to 1.07, P<0.00001). The overall morbidities of anxiety and depression in patients with uveitis were 39% and 17%, respectively. With subgroup analysis, the heterogeneity actually came from different kinds of uveitis. Specifically, the incidence rates of both anxiety and depression were relatively low in patients with anterior uveitis (33% and 15%), moderate in patients with infectious uveitis (46% and 22%), and high in patients with unspecified uveitis (59% and 35%).

CONCLUSION

It is preliminarily indicated that patients with uveitis may have a high risk of anxiety and depression. Ophthalmologists and psychologists should pay more attention to the psychological state when dealing with patients with uveitis. Further high-quality studies with detailed direct data are needed to draw more precise conclusions.

The prevalence of anxiety symptoms and disorders among ophthalmic disease patients

Background:

Progressive and irreversible vision loss has been shown to place a patient at risk of mental health problems such as anxiety. However, the reported prevalence of anxiety symptoms and disorders among eye disease patients vary across studies. Thus, this study aims to clarify the estimated prevalence of anxiety symptoms and disorders among ophthalmic disease patients.

Methods:

Relevant studies on the prevalence of anxiety symptoms and disorders among eye disease patients were collected through international databases, PubMed, Scopus, and Web of Science. A random-effects model was used to determine the pooled prevalence of anxiety symptoms and disorders among ophthalmic disease patients.

Results:

The 95 included studies yielded a pooled prevalence of 31.2% patients with anxiety symptoms and 19.0% with anxiety disorders among subjects with ophthalmic disease. Pediatric patients were more anxious (58.6%) than adults (29%). Anxiety symptoms were most prevalent in uveitis (53.5%), followed by dry eye disease (DED, 37.2%), retinitis pigmentosa (RP, 36.5%), diabetic retinopathy (DR, 31.3%), glaucoma (30.7%), myopia (24.7%), age-related macular degeneration (AMD, 21.6%), and cataract (21.2%) patients. Anxiety disorders were most prevalent in thyroid eye disease (TED, 28.9%), followed by glaucoma (22.2%) and DED (11.4%). When compared with healthy controls, there was a twofold increase on the prevalence of anxiety symptoms (OR = 1.912, 95% CI 1.463–2.5, p < 0.001) and anxiety disorders (OR = 2.281, 95% CI 1.168–4.454, p = 0.016).

Conclusion:

Anxiety symptoms and disorders are common problems associated with ophthalmic disease patients. Thus, comprehensive and appropriate treatments are necessary for treating anxiety symptoms and disorders among ophthalmic disease patients.

Confronting and Coping with Multidrug-Resistant Tuberculosis: Life Experiences in Thailand

In this article, we aimed to understand the life experiences of Thai persons diagnosed with multi-drug-resistant tuberculosis (MDR-TB). A qualitative study using a face-to-face in-depth interview was conducted at a hospital in Thailand which has the highest prevalence of MDR-TB in the country between January and February 2019. Twenty persons living with MDR-TB in Thailand were purposively selected to represent a variety of experiences based on different gender, ages, and treatment phases. Qualitative data were transcribed and thematic analysis was applied to identify common themes and sub-themes. The results indicated that all participants faced emotional difficulties, such as fear of death, fear of stigmatization, confusion, and sadness when first knowing of their diagnosis. Family and social support were the main ways that the patients coped with difficult situations. Suicidal ideas were more prevalent among patients with poor family support. Screening for mental health problems should be routinely performed in MDR-TB patients. Proper health education should be provided to patients and families to reduce emotional difficulties and stigmatization.

The Association Between Mental Health Disorders and Non-Infectious Scleritis: A Prevalence Study and Review of the Literature

Chronic inflammatory diseases can cause significant psychosocial stress in affected patients. Few studies have examined the psychological effects of ocular inflammatory disease and no studies have examined the psychological effects of scleritis. In this study we evaluate the prevalence of mental health disorders in scleritis patients and we conduct a comprehensive review of the literature on the mental health effects of ocular inflammatory diseases. 162 patients (195 eyes) presenting to a tertiary care center with scleritis were identified. At least one comorbid mental health disorder was diagnosed in 35 patients (21.6%), most commonly major depression in 11.7%, generalized anxiety disorder in 9.3%, and substance use disorder in 6.2%. There were no significant differences in the length of an episode of scleritis or in the probability of symptom resolution between patients with a mental health disorder and other patients. In a review of the literature, 30 manuscripts met the inclusion criteria. The majority of manuscripts (83.3%) were focused on uveitis patients. Eight of these studies were focused on patients with uveitis in the context of systemic disease. The most commonly reported mental health disorders reported were anxiety and depression. An average of 31.3% of patients with ocular inflammatory disease had depression and 35.0% had anxiety. Similar to other chronic illnesses, ocular inflammatory disease may be a significant psychosocial stressor. Future studies will further elucidate the relationship between these diseases and mental health.

Vision-Related Quality Of Life And Depression In Brazilian Patients With Toxoplasmic Retinochoroiditis

PURPOSE

To investigate visual-related quality of life (VRQL) and prevalence and severity of depressive symptoms in Brazilian individuals with toxoplasmic retinochoroiditis (TRC).

DESIGN

Comparative observational cross-sectional study. The National Eye Institute Visual Function Questionnaire-25 (NEI-VFQ-25) and Beck Depression Inventory-II (BDI-II) were applied to respectively assess VRQL and depression in individuals consecutively seen at a uveitis referral center. Clinical/demographical data were collected. Descriptive/analytic statistics were employed, with P<0.05.

RESULTS

Patients and controls were comparable concerning age, sex and socioeconomic level. VRQL scores for all subscales were significantly lower in TRC when compared with controls, particularly associated (P<0.05) with female sex, history of ≥2 prior TRC recurrences, concomitant use of systemic corticosteroids, monocular vision and blindness. Depressive symptoms were more prevalent in TRC (55/188; 29.2%) than in controls (34/182; 18.7%) (P=0.023), also being associated with lower VRQL scores (P<0.001). Seropositive and seronegative controls for toxoplasmosis had similar VRQL scores and comparable rates of depressive symptoms.

CONCLUSION

TRC affects VRQL in Brazilian individuals, particularly women, using systemic corticosteroids, with visual impairment and presenting recurrences of TRC. One-third of patients with TRC had evidence of depression, which was also associated with lower VRQL scores. Mental health issues in subjects with TRC should not be overlooked.

The Readability of Ophthalmological Patient Education Materials Provided by Major Academic Hospitals

INTRODUCTION

The internet is an increasingly important resource for patients seeking health-related information. Because of this trend, the American Medical Association (AMA) and National Institutes of Health (NIH) recommend that online patient education materials (PEMs) be written between a third and seventh grade level. The present study evaluates the readability levels of ophthalmological PEMs provided by five major academic hospitals, quantifies the availability of accompanying videos and graphics, and examines the extent to which readability may be increased.

METHODS

In March 2021, 397 PEMs from five major academic hospitals were extracted for subsequent analysis by seven validated readability assessments. The presence of an accompanying video or graphic was noted. Statistical significance was assessed using the Kruskal-Wallis test with Dunn's multiple comparisons test and the chi-square test.

RESULTS

Nearly all articles were written above the recommended reading level of 7^th grade. After averaging the scales for each article, the median grade level was 11.7 (interquartile range [IQR], 10.7-12.7). The PEMs with the highest median reading level were provided by the Johns Hopkins University Wilmer Institute (12.6, IQR, 11.3 - 13.6). Only 13.6% and 13.1% of articles had an accompanying video and graphic, respectively. Reduction of sentence length beneath 15 words resulted in an improvement of readability by 2.7 grade levels.

CONCLUSIONS

The readability of online patient resources provided by major academic hospitals were above the literacy guidelines recommended by the NIH and AMA. Furthermore, most articles did not include a video or graphic, both of which could potentially improve patient understandability of educational materials. By altering these PEMs, as demonstrated here, institutions could increase the value these articles provide for patients and therefore the quality of the patient-physician relationship.

Health Literacy, Medication Adherence, and Quality of Life in Patients With Uveitis

Purpose: To evaluate health literacy, medication adherence, and quality of life (QOL) in uveitis patients.Methods: Cross-sectional quality improvement study using questionnaires of health literacy (Short Assessment of Health Literacy), adherence (Beliefs about Medicine Questionnaire), and QOL (12-item Short Form Health Survey).Results: Sixty patients were surveyed: 57% women, 80% identified as Black, and 42% with schooling beyond high school. Forty-three percent of the patients had poor health literacy, with lower scores among those with less schooling (p < .01). Necessity scores were higher for multiple providers (p = .02). Necessity (p = .03) and Concerns (p < .01) scores were higher for patients seeing a rheumatologist. Patients had lower physical (p < .01) and mental QOL (p < .01) than the general US population.Conclusions: Uveitis patients reported many barriers to care. Despite strong perceptions of treatment necessity, there were significant concerns, especially among patients seeing a rheumatologist. We recommend multidisciplinary care, individualized education, and counseling regarding medication safety and the necessity to improve adherence.

Epidemiology of Uveitis in a Spanish Region: Prevalence and Etiology

OBJECTIVE

To estimate the prevalence of uveitis and to describe its etiologic and anatomical patterns based on a population study carried out in a Spanish region.

MATERIAL AND METHODS

A cross-sectional, descriptive, population-based multicenter study was conducted. The selection criteria consisted of having a diagnosis of uveitis. All data were collected from existing information in medical records.Clinical information was collected in all cases that had a diagnosis of uveitis, regardless of its etiology, in participating centers from the date of the study to the end of the following year. All patients underwent a complete ophthalmological examination, which included assessment of their visual acuity, biomicroscopy, applanation tonometry, and indirect ophthalmoscopy.

RESULTS

During the study, 389 cases of uveitis were registered. The prevalence was 58.7 (95% confidence interval [CI] 53.0-64.9). The mean age was 47.0 ± 20.6 years and 57.8% were women. The most prevalent anatomical pattern was anterior uveitis (54.2; 95% CI 48.1-60.8). For adults, the idiopathic group constituted the highest prevalence (31.7; 95% CI: 27.1-36.9), while autoimmune etiology was most frequent for children (10.6; 95% CI: 5.8-17.7).

CONCLUSION

The results of this population-based study offer a representative estimate of the magnitude of uveitis in this area of Spain.

Economic Hardship, Ocular Complications, and Poor Self-reported Visual Function are Predictors of Mental Problems in Patients with Uveitis

PURPOSE

To characterize the quality of life and mental health status of patients with uveitis and investigate predictors of psychological problems.

METHODS

A total of 245 patients and 105 controls were enrolled in this cross-sectional study. Quality of life, psychological status, socio-demographic and clinical data were obtained from questionnaires and medical records. Multivariate regression analyses and Receiver Operating Characteristic (ROC) were applied to obtain the model predicting psychological problems of patients.

RESULTS

Of 245 patients, 16.7% and 26.5% (P < .0001) screened positive for anxiety and depression, respectively. The model predicting anxiety was comprised of low annual household income and poor self-reported visual function (P = .029, P < .0001, respectively), with an AUC of ROC of 0.744. The model predicting depression was comprised of poor self-reported visual function and ocular complications (P < .0001, P = .012, respectively), with an AUC of 0.78.

CONCLUSIONS

Economic hardship, ocular complications, and poor self-reported visual function are predictors of mental problems in patients with uveitis.

Time Trade-off Utility Values in Noninfectious Uveitis

PURPOSE

To investigate time trade-off (TTO) utility values in patients with noninfectious uveitis and determine whether patient demographics and clinical characteristics are associated with utility scores.

DESIGN

Time trade-off utility analysis.

METHODS

Setting: A tertiary care uveitis center in San Francisco, California, USA.

PATIENT POPULATION

One hundred and four consecutive adults with noninfectious uveitis, enrolled between November 2016 and February 2017.

MAIN OUTCOME MEASURES

TTO utility values, as collected by an interviewer-guided survey. Information regarding general health, ocular symptoms, and religion was also collected and medical record review was conducted to record anatomic location of uveitis, disease activity, visual acuity, and treatments. Multivariable regression analysis with backward selection was used to identify variables associated with TTO values.

RESULTS

Median TTO score was 0.975 (interquartile range [IQR]: 0.8-1.0), corresponding to trading a median 1.28 years of remaining life for healthy eyes (IQR: 0-6.29). Regression analysis revealed that worse eye visual acuity, >6 months of oral corticosteroid use, and current antidepressant use were associated with lower TTO scores (P = .008, P = .006, P = .008, respectively), controlling for age and sex. In particular, patients who had been taking oral corticosteroids for more than 6 months, regardless of dose, were 10.5 times more likely to trade 20% or more years of remaining life (TTO ≤0.8) than patients not taking oral corticosteroids (95% confidence interval: 2.3, 48.1; P = .002).

CONCLUSIONS

Patients with noninfectious uveitis had measurable, though modest, reductions in quality of life, as assessed by TTO, and these decreases were significantly associated with visual acuity in the worse eye and long-term oral corticosteroid use.