European Journal of Cardiovascular Medicine

Glaucoma is a chronic eye disease characterized by progressive optic nerve damage leading to irreversible visual field disorders [1]. In 2020, it was estimated that 80 million people worldwide had glaucoma, but this number is expected to increase to more than 11.18 million by 2040 [2]. Glaucoma represents a significant economic and psychological burden for patients [3, 4]. It has been reported that there is a statistically significant association between glaucoma and anxiety and depression [5]. As the therapeutic approach to glaucoma involves controlling intraocular pressure (IOP) using a combination of drugs, underlying anxiety and depression in glaucoma patients may cause poor adherence to treatment and thereby accelerate disease progression [6]. A health psychology approach to glaucoma therapy should pay attention to the management of mental health problems associated with the disease [6]. The COVID  lockdown was strictly followed and it disrupted follow-up plans for glaucoma patients, leaving most patients without access to personal care. The ability to purchase eye drops and monitor intraocular pressure was limited, which can affect the mental health of glaucoma patients through anxiety and depression.

Self-management support is a behavioral strategy that maintains healthy outcomes and improves a person's condition by monitoring and regulating behavior and reinforcement. Recent research has suggested that self-management intervention has a beneficial impact on improving quality of life and can reduce the incidence of depression and anxiety in patients with chronic disorders such as diabetes, stroke, nephropathy and age-related macular degeneration [8–13]. Self-management can play a positive role in the mental health of glaucoma patients. However, there are few reports on the psychological burden and self-management of glaucoma patients. The Generalized Anxiety Disorder Scale (GAD-7) is a valid and effective tool for screening for generalized anxiety disorder and assessing its severity in clinical practice and research, with excellent internal reliability (Cronbach's α = 0.92) and good test–retest reliability ( intraclass correlation = 0.83) [14]. The Patient Health Questionnaire (PHQ-9) is a validated, easy-to-administer depression screening questionnaire with excellent internal reliability (Cronbach's α = 0.89) and good test–retest reliability (intraclass correlation = 0.84) [ 15 ]. The Glaucoma Self-management Questionnaire (GSMQ) has been found to show good reliability and validity as a recommended tool for assessing self-management behavior in patients with glaucoma. In this study, we examined anxiety, depression, and self-management scores of glaucoma patients during the COVID-19 pandemic through the GAD-7, PHQ-9, and GSMQ, and examined the association between self-management and mental health.

Study participants and survey method

This cross-sectional study included patients aged 18 years and older from the Glaucoma Clinics of Eye Hospital of a tertiary medical hospital in central India. Patients were included if they were treated with medical therapy and voluntarily joined the case management platform with regular follow-up. Participants were excluded if they had any previous eye surgery or cognitive impairment in the past 2 months. We focused primarily on glaucoma patients with medical treatment and regular follow-up. Therefore, only patients with primary open-angle glaucoma (78.3%) and patients with chronic angle-closure glaucoma (CACG, 21.7%) were included in this study. Because CACG was less frequent, we did not perform further analysis according to different subtypes of glaucoma. Whatsapp-based electronic questionnaires were sent to enrolled participants from March 1, 2020 to June30, 2020.

All participants were introduced to the purpose of this study with standard instructions by the assigned case manager, and informed consent was obtained prior to their participation. To ensure the efficiency and integrity of this study, all questions were mandatory and each respondent, identified by telephone number, could answer the questionnaire only once. A total of 218 questionnaires were sent out and 218 questionnaires were returned (response rate: 100%). Before data analysis, the logic of the questionnaires was checked by the case manager. This study was conducted in accordance with the principles of the Declaration of Helsinki.

Assessment of mental health and self-management

The GAD-7 contains 7 questions based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) symptom criteria for GAD. The scale of each question ranges from 0 (not at all) to + 3 (almost every day). A total score was calculated by summing the responses to the 7 items. Total scores of 0–4, 5–9, 10–14, and 15–21 was interpreted as minimal, mild, moderate, and severe levels of anxiety on the GAD-7.

The PHQ-9 consists of 9 items based on the DSM-IV symptom criteria for depressive disorder, scoring each of the 9 DSM-IV criteria as 0 (not at all) to + 3 (almost every day). Total scores range from 1 to 27. Cut points of 5, 10, and 15 represent mild, moderate, and severe levels of depression, respectively.

The GSMQ includes 17 items that assess the following 3 domains: adjustment to life, support of physical function, and medical management of illness. A 4-point Likert scale is used for each item. The range of the scale is 1 (can't do it at all) to + 4 (can do it completely). A total score is calculated by summing the responses to the 17 items. A higher total score indicates higher self-management.

A total of 218 glaucoma patients (122 men and 94 women; mean age 45 ± 16 years) were included in this study. Demographics of the total sample are presented in Table 1.

Anxiety, depression and self-control

During the COVID-19 pandemic public emergency, 100 (45.9%) glaucoma patients self-reported higher levels of anxiety, while 58 (26.6%) patients reported higher levels of depression. The mean GAD-7 and PHQ-9 scores in the study population were 2.2 ± 3.2 and 3.2 ± 3.8, respectively. The proportion of depression and anxiety was 26.5% (n = 58) and 20.1% (n = 44). Most participants had mild levels of depression (44/58, 75.8%) and minimal levels of anxiety (36/44, 81.7%).

The results of our study showed that the psychological burden of anxiety and depression was particularly severe during the COVID-19 epidemic. The proportion of generalized anxiety disorder among glaucoma patients in this study was 20.2%, which was higher than in the United States , Turkey  and Japan . and Europe  before the COVID-19 epidemic. The proportion of depression was , which was high compared to previous studies in the United States Australia  China , Hungary ( Japan (10.9%) [18] and countries in Europe  before the COVID-19 epidemic.

The proportion of anxiety and depression among glaucoma patients was higher than usual during the COVID-19 pandemic in Central India. Self-management was negatively correlated with depression in glaucoma patients. Self-management questionnaires can be incorporated into the workflow of glaucoma clinics. Helping glaucoma patients to self-manage through self-management education is essential, especially among young men with low levels of education

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