Anxiety, depression, and sleep related outcomes of glaucoma patients: systematic review and meta-analysis

Authors: Groff ML, Choi B, Lin T, Mcllraith I, Hutnik C, Malvankar-Mehta MS.

Geographical coverage: United States of America (USA), Japan, China, Australia, Germany, Turkey, Canada. Taiwan, Brazil, France, Greece, Israel, Italy, Nigeria, Norway, and Singapore.

Sector: Prevalence

Sub-sector: Mental health

Equity focus: Not reported

Study population: Patients with glaucoma

Review type: Effectiveness review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis method: Not applicable

Background

Glaucoma is the second leading cause of blindness worldwide and is becoming increasingly common as the global population ages. While glaucoma’s effects on vision are well documented, its psychosocial effects are less frequently discussed. Loss of vision can have a profound impact on mental health. It is not uncommon for patients with glaucoma to experience psychological distress, including symptoms of depression and anxiety, as well as poor sleep quality. These comorbid conditions may adversely affect treatment adherence. Although some evidence has linked glaucoma with diminished mental health and vision-related quality of life, no comprehensive review had previously evaluated the overall burden of depression, anxiety, and sleep disturbances in this patient population.

Objectives

This review aimed to quantify the prevalence and severity of depression, anxiety, and sleep disturbances among adult patients with glaucoma.

Main findings

The review included 45 studies, conducted in 17 countries, involving adult patients with glaucoma. Of the 45 included studies, 38 (84%) assessed depression, 21 (47%) assessed anxiety, and nine (20%) assessed sleep-related outcomes. The prevalence of depression among patients with glaucoma was estimated at 19% (95% CI: 16%–23%). Compared to patients without glaucoma, those with glaucoma had significantly higher depression scores, with a pooled standardised mean difference (SMD) of 0.46 (95% CI: 0.19–0.73). Depression symptoms were particularly elevated among patients with primary angle-closure glaucoma (PACG), with an SMD of 1.77 (95% CI: 1.31–2.24).

Anxiety was also more common in glaucoma patients than in those without the condition, with a pooled prevalence of 25% (95% CI: 21%–30%). The pooled SMD for anxiety severity was 0.44 (95% CI: 0.08–0.81). Among patients with PACG, anxiety symptoms were especially pronounced (SMD: 1.38, 95% CI: 0.94–1.82). Primary open-angle glaucoma (POAG) was also associated with higher anxiety symptoms (SMD: 0.66, 95% CI: 0.16–1.17).

In studies assessing sleep-related outcomes, the pooled prevalence of sleep disturbances was 47% (95% CI: 26%–68%). Patients with glaucoma had significantly worse sleep quality than those without glaucoma, with a pooled SMD of 0.72 (95% CI: 0.22–1.21). Sleep problems were especially severe in PACG patients (SMD: 1.48, 95% CI: 1.14–1.82), and elevated in those with POAG (SMD: 1.05, 95% CI: 0.34–1.76).

Methodology

A systematic search was conducted across MEDLINE, Embase, PsycINFO, the Cochrane Library, Web of Science, OpenGrey, and ProQuest Dissertations. The inclusion criteria were observational studies in English with a sample size greater than 20, that clearly defined glaucoma and reported outcomes related to depression, anxiety, sleep quality, quality of life, or medication adherence. Two reviewers independently screened titles, abstracts, and full texts, resolving discrepancies through discussion. One reviewer extracted data from each included study, and a second verified its accuracy. Quality and risk of bias were assessed using the Downs and Black checklist. Meta-analysis was conducted using a fixed-effects model to pool SMDs with 95% confidence intervals. Heterogeneity was assessed using the chi-square test and I² statistic. When significant heterogeneity was present, a random-effects model was applied. Begg’s funnel plot was used to assess publication bias.

Applicability/external validity

Studies were conducted in a diverse range of settings across 17 countries, enhancing the generalisability of the findings. However, heterogeneity in study design, glaucoma subtype, control group characteristics, and measurement tools may limit applicability to specific populations.

Geographic focus

The 45 studies were conducted across 17 countries: USA (13 studies), Japan (6), China (5), Australia (3), Germany (3), Turkey (3), Canada (2), Taiwan (2), Brazil (1), France (1), Greece (1), Israel (1), Italy (1), Nigeria (1), Norway (1), and Singapore (1).

Summary of quality assessment

Appropriate meta-analytic methods were used, but the search strategy was not fully comprehensive, and some relevant studies may have been missed. Included studies varied in design, participant demographics, and outcome measurement. These limitations should be considered when interpreting the pooled results. Despite this, consistent patterns across studies support the conclusion that glaucoma patients experience increased psychological and sleep-related burden.