Depressive and generalized anxiety symptoms in adults awaiting cataract surgery in India

Study setting and sample

The study population comprised adults presenting to the ophthalmology department of four tertiary, not-for-profit eye hospitals. They were either walk-in patients or referrals from outreach eye screening camps.

A random-proportional sampling technique was adopted to sample all eligible participants. The sample was proportionately distributed among the four hospitals based on the volume of annual cataract surgeries performed during the preceding financial year. Individuals aged 18 years and above who presented for the first eye surgery with no obvious cognitive or auditory deficits and who could understand at least one of the following four languages—Gujarati, Marathi, Hindi or English—were considered eligible for participation. The calculation of the sample size was based on two prior studies of relevance. Both were longitudinal studies that looked at the impact of cataract surgery on depression symptoms using the Center for Epidemiological Studies–Depression Scale (CES-D) before and after cataract surgery.^26,28 The mean depressive symptom scores from these studies decreased from 8.03 before surgery to 7.02 at follow-up.^26,28 To observe a similar improvement in depressive symptoms post-surgery with two-sided statistical significance of 5% and 90% power, 632 patients would be required. This was increased to 820 to account for a 30% loss to follow-up in a longitudinal study.

Data collection: Baseline

Standard research protocols were followed during data collection in accordance with the Declaration of Helsinki. Patients were recruited at the preoperative inpatient wards wherein beds were laid out in an organized fashion. A systematic listing of the occupants available was undertaken to document their age, whether first-eye cataract surgery, language spoken by them and presence of any cognitive or auditory anomalies were recorded. This information was used to identify the eligible participants for the study. A potential respondent was chosen to participate in the study from every third or fifth bed depending on the sample size required from each hospital, with the first respondent chosen randomly from the sampling interval. Once identified, each potential participant was contacted by an interviewer trained in the study procedures with the assistance of the hospital staff. Before starting the interview, each participant was explained the nature and purpose of the interview and their written informed consent for participation was obtained. Subsequently, participants were interviewed in an isolated area outside the inpatient ward of the hospital. All participants had the right to refuse participation or stop the interview anytime. The average interview time was 45 minutes. Interviews were recorded on paper.

Measures

The interview documented sociodemographic characteristics of the patients including age, gender, education, occupation, place of residence, current living arrangements, visual acuity and spectacle use. Details on preoperative visual acuity, type of cataract, comorbid ocular conditions other than cataract, cataract in the fellow eye and eye selected for cataract surgery were extracted from the individual patient medical records available with the treating hospitals.

Depression

The 20-point CES-D scale was used in the study population, which determined the one-week prevalence of sub-threshold depression.^29,30 This scale was previously used to assess depressive symptoms in ophthalmic patients suffering with cataracts including among Indian adult populations.^{13,17,26,28,31–33}

The CES-D was used because it provides an estimate of symptoms appropriate for the goals of an epidemiological study, rather than a diagnostic test or screen for clinical depression.²⁶ This scale was translated into the local languages for use by the researchers, and then was back-translated and field-tested to ensure proper readability. The researchers closely collaborated with mental health experts and the participating hospital staff to achieve the accuracy of cultural understanding and translation. The respondents were asked to rate the degree to which they experienced each depression-related symptom on a 4-point frequency scale: rarely or none of the times (<1 day); some or a little of the times (1–2 days); occasionally or a moderate amount of time (3–4 days) and most or all of the time (5–7 days) and the possible scores for CES-D ranged from 0 to 60. A continuous overall score between 0 and 60 was produced, with higher scores representing more depressive symptoms. A CES-D score of 16 or higher has previously been considered suggestive of a ‘significant’ level of depressive symptoms in adults.^{13,17,26,28–30}

Generalized anxiety disorder

We used the 7-point Generalised Anxiety Disorder scale (GAD-7), which is designed to assess generalized anxiety (GA) disorder symptoms in adults.^34–38 The respondents were asked to rate the degree to which they experienced each GA symptom on a 4-point frequency scale (not at all, several days, over half of the days and nearly every day). The possible scores ranged from 0 to 21, and scores of 5, 10 and 15 represent cut-off points for mild, moderate and severe anxiety disorder symptoms, respectively.^34–38 A GAD-7 score of 10 or higher has previously been considered suggestive of a ‘significant’ level of anxiety disorder symptoms in adults.^34–38 The GAD-7 scale too was appropriately translated into local languages, and then was back-translated and field-tested to ensure proper readability. We used the GAD-7 scale as it had high sensitivity and good specificity for detecting GA disorder.³⁸

Abuse/mistreatment and neglect

History of abuse or mistreatment and neglect by friends, family or relatives due to their vision was documented. Neglect was defined as denial of basic needs such as food and shelter. Mistreatment was defined as subjecting patients to verbal abuse, threat of violence, physical beatings or mental abuse. ‘Neglect’ by family and friends and ‘abused/mistreated’ by family were assessed separately. In addition, current difficulty in performing daily tasks as well as requiring help with daily tasks was also documented.

Visual acuity

Measures of visual impairment (VI) were classified into six broad categories as defined by the International Statistical Classification of Diseases and Related Health Problems (ICD-10) as mild or no VI (equal to or better than 6/18), moderate VI (worse than 6/18–6/60), severe VI (worse than 6/60–3/60), blindness level-1 (worse than 3/60–1/60 or finger counting at 1 metre), blindness level-2 (worse than 1/60 to light perception) and blindness level-3 (no light perception).³⁹ The baseline visual acuity details were noted from the patient medical records available at the treating hospital.

Statistical analysis

Microsoft Office Excel 2013 and SPSS statistical software (Version 20.0, SPSS Science, Chicago, IL, USA) were used to analyse the data. Descriptive statistics for depression and GA scores are reported for relevant variables, and Chi-square test and one-way ANOVA test were used to assess significance as appropriate.⁴⁰ The association of depression with GA score is presented separately for men and women patients. We report the prevalence of depression score >16 and GA score >10, among these adults.^{29,30,34–38} Multiple classification analysis (MCA) was performed to assess the variation in intensity of depression and anxiety with select factors. We used depression and GA scores as continuous variables in MCA, as clinical cutoff scores for these conditions are not readily available for adults in India. For MCA, neglect and mistreated variables were combined into one as they seem not to be fully independent of one another. A similar re-categorization was done for the variables ‘facing difficulty in performing daily tasks’ and ‘need help with daily tasks’; 95% confidence intervals (CI) are reported as appropriate.

Participation and demography

A total of 829 adults aged 18 years and above were approached from four tertiary not-for-profit eye hospitals of whom 813 (98.1%) participated. Of the 813 participants, over half were men (56.1%) and three-fourths were aged between 50 and 70 years (74.8%). The median ages were 62 and 60 years for men and women, respectively. About two-thirds were currently married (66.8%). Most participants had no formal education (57.4%), and about one-third were currently not working (36.2%). Over half were currently living with both their children and spouse (59.4%; Table I).

Clinical characteristics and visual acuity

A total of 401 (55.1%; men 57.6%, women 51.9%) had moderate VI, followed by those with severe VI (19.2%) and 84 (11.5%) were blind. A significantly higher proportion of women were blind compared to men (45, 14.2%; p=0.042). A significantly higher proportion of men suffered from comorbid ocular conditions than women (426, 52.4%; p=0.01).

Abuse/mistreatment and neglect faced due to vision

Men (383, 84%) were significantly more likely to report facing difficulties in performing daily tasks than women because of their vision (284, 79.6%; p=0.02). Similarly, significantly more men (315, 69.1%) reported being neglected by family/friends because of their vision as compared with women (228, 63.9%; p=0.003). A total of 443 (54.5%) adults reported requiring help from others to perform their daily activities, the majority of whom were women (60.8%; p=0.001). The proportion of adults who reported staying at home most of the time due to their vision was higher among women (59.4%) than men (48.5%; p=0.001; Table I).

Distribution of scores

The overall mean (SD) depression and GA scores were 24.6 (7.8) and 6.3 (4.2) for men and 25.8 (8.9) and 6.9 (4.4) for women, respectively (Table II). Among men awaiting cataract surgery, significantly higher levels of mean depression score were observed among those who reported being neglected or mistreated by their family and friends (28.1, p<0.001), followed by those who were never married (27.7, p<0.032) and those reportedly facing difficulty in performing their daily tasks and required help (27.2, p<0.001). Similarly, the highest levels of mean GA score were also observed among those who reported being neglected or mistreated by their family and friends (7.6, p<0.001) followed by those reportedly facing difficulty in performing their daily tasks and requiring help (7.5, p<0.001) and those with severe VI (7.4, p=0.047). Among women awaiting cataract surgery, the highest levels of mean depression score were among those who reported being neglected or mistreated by their family and friends (30.9, p<0.001), followed by those reportedly facing difficulty in performing their daily tasks and requiring help (28.2, p<0.001) and those with severe VI (28.1, p=0.047). Similarly, the highest levels of mean GA score were observed among those who reported being neglected or mistreated by their family and friends (8.5, p<0.001) followed by those who were 70 years and older (8.4, p=0.001) and those who were blind (8, p=0.044).

The distribution of overall scores for depression and GA was clustered around middle-aged groups of 50–70 years (p=0.001, Fig. 1). However, a bulk of these scores were clustered above and below the clinical cut-off level for depression and GA, respectively.

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FIG 1.

Distribution of depression score with Center for Epidemiologic Studies–Depression (CES-D) scale,^29,30 (upper) and generalized anxiety scores using the Generalised Anxiety Disorder-7 (GAD-7) scale,^34–38 (lower) by age for adults awaiting cataract surgery in India. A CES-D of >16 and GAD-7 score of >10 is considered suggestive of significant levels of depressive and generalized anxiety symptoms^{29,30,34–38} The horizontal black line depicts the clinical cut-off for depression and anxiety.

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The overall prevalence of depression (CES-D) score of 16 or higher was 87.4% (95% confidence interval [CI] 84.7%–89.6%), and GA (GAD-7) score of 10 or higher was 57.1% (95% CI 53.5%– 60.7%). The prevalence of depression and GA with these scores among men was 88.8% (95% CI 85.3%–91.5%) and 54.9% (95% CI 50%–59.7%), respectively. The prevalence of these in women was 85.5% (95% CI 81.2%–89%) and 60.1% (95% CI 54.5%– 65.3%), respectively.

The prevalence of comorbid depression and anxiety symptoms was 56.6% (95% CI 52.9%–60.2%), which was higher in women, 59.4% (95% CI 53.8%–64.9%) compared to men, 54.4% (95% CI 49.4%–59.3%; p=0.098). The prevalence of depression and anxiety comorbidity was significantly higher in those who reported suffering from ocular comorbid conditions other than cataract, 61.8% (95% CI 56.7%–66.7%; p<0.001, Fig. 2).

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FIG 2.

Association between depressive and generalized anxiety symptoms using the Center for Epidemiologic Studies–Depression (CES-D) and Generalised Anxiety Disorder-7 (GAD-7) scales^{29,30,34–38} among adults awaiting cataract surgery in India * Chi-square test for significance: p=0.098 † Comorbid ocular conditions other than cataract, Chi-square test for signifiance: p<0.001 ‡ Grades of VI measured as per the ICD-10 classification. Chi-square test for signifiance: p<0.109

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Determinants of depression and generalized anxiety

Table III shows the MCA for the adjusted predicted mean scores for depression and GA scores. Those reported being neglected and mistreated by family/friends due to their vision, those who were finding it difficult to perform their daily tasks and required help and those suffering from comorbid ocular conditions other than cataract had the highest effect on the intensity of depression with a beta value of 0.352, 0.303 and 0.147, respectively. Correspondingly, being neglected and mistreated by family/friends due to their vision, those who were finding it difficult to perform their daily tasks and required help, and those staying home most of the time due to their vision had the most impact on GA (β 0.219, 0.211 and 0.125), respectively.

Conclusion

Psychosocial needs of adults awaiting cataract surgery are often neglected while designing the eye care programme. As most eye care services are provided from stand-alone eye health facilities, there is a need for specific interventions and to build and sustain robust referral mechanisms with qualified mental health practitioners. Training existing eye care service providers (AOP) in the identification of mental health issues and incorporating these into the regular service delivery mechanisms would address this problem to an extent. Investing in patient counselling services and recruiting CHWs to boost awareness locally and to improve uptake of cataract surgical services seems a viable option. Our study has contributed to the evidence and further work is needed to understand the long-term impact of cataract on the mental health of adults.