The relationship between diabetic retinopathy and psychosocial functioning: a systematic review
Previous work has reported a link between diabetic retinopathy/diabetic macular edema (DR/DME) and psychosocial functioning, although the extent and direction of the association remains uncertain.
To determine the relationship between DR/DME and psychosocial functioning, the latter an umbrella term used to capture the emotional and social aspects of functioning which may include, for example, depression; depressive disorder; anxiety; vision-specific distress; diabetes-specific distress and emotional and social well-being.
PubMed, Embase, Medline and the Cochrane Central register were systematically searched for relevant interventional and observational quantitative studies using standardised criteria. Studies with DR/DME and psychosocial functioning as exposures or outcomes were accepted. Study quality was evaluated using the modified Newcastle–Ottawa scale for observational studies, and the modified Down’s and Black checklist for interventional studies.
Of 1827 titles initially identified, 42 were included in the systematic review. They comprised of four interventions (one RCT, three non-RCTs) and 38 observational studies (33 cross sectional, five prospective). In studies with DR/DME as the exposure (n = 28), its severity and related vision impairment were consistently associated with poor psychosocial outcomes, mostly higher incidence of depression and depressive symptoms. Baseline depression and depressive symptoms were also associated with greater DR incidence and progression of DR. Medical intervention strategies showed significant improvement in psychosocial outcomes in patients with DR, such as significant improvements in mental health domain scores of the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ 25).
Conclusion and relevance
Severity of DR, DME and associated vision loss are significantly associated with poor psychosocial outcomes. Aspects of depression and its symptoms show a bi-directional association, with increased incidence and progression of DR significant in those with baseline depression or depressive symptoms. Based on these findings, we propose two areas that may benefit from targeted interventions: (1) Prevention of development of poor psychological outcomes by preventing and delaying progression of DR/DME; and (2) Improved detection and management of poor psychological functioning by improving screening tools and multidisciplinary care for patients. Subsequent longitudinal studies can further help establish the underlying relationship between the two measures.
KeywordsDiabetic retinopathy Depression Quality of life Vision impairment Psychosocial
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflicts of interest.
- 14.Fenwick, E. K., Cheng, G. H., Man, R. E. K., et al. Inter-relationship between visual symptoms, activity limitation and psychological functioning in patients with diabetic retinopathy. British Journal of Ophthalmology, 102(7), 948–953. 2017.Google Scholar
- 16.Ishizawa, K., Babazono, T., Horiba, Y., et al. (2016). The relationship between depressive symptoms and diabetic complications in elderly patients with diabetes: Analysis using the diabetes study from the Center of Tokyo Women’s Medical University (DIACET). Journal of Diabetes and its Complications, 30(4), 597–602.CrossRefGoogle Scholar
- 22.Deeks, J. J., Dinnes, J., D’Amico, R., et al. (2003). Evaluating non-randomised intervention studies. Health Technology Assessment (Winchester, England), 7(27), iii–xGoogle Scholar
- 26.von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gotzsche, P. C., & Vandenbroucke, J. P. (2014). The Strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. International Journal of Surgery (London, England), 12(12), 1495–1499.CrossRefGoogle Scholar
- 28.Poongothai, S., Anjana, R. M., Pradeepa, R., et al. (2011). Association of depression with complications of type 2 diabetes–the chennai urban rural epidemiology study (CURES-102). The Journal of the Association of Physicians of India, 59, 644–648.Google Scholar
- 33.Ratanasukon, M., Tongsomboon, J., Bhurayanontachai, P., & Jirarattanasopa, P. (2016). The impact of vision impairment (IVI) questionnaire; validation of the Thai-version and the implementation on vision-related quality of life in Thai rural community. PLoS ONE, 11(5), e0155509.CrossRefGoogle Scholar
- 39.Granstrom, T., Forsman, H., Leksell, J., Jani, S., Raghib, A. M., & Granstam, E. (2015). Visual functioning and health-related quality of life in diabetic patients about to undergo anti-vascular endothelial growth factor treatment for sight-threatening macular edema. Journal of Diabetes and its Complications, 29(8), 1183–1190.CrossRefGoogle Scholar
- 40.Das, T., Wallang, B., Semwal, P., Basu, S., Padhi, T. R., & Ali, M. H. (2016). Changing clinical presentation, current knowledge-attitude-practice, and current vision related quality of life in Self-reported type 2 diabetes patients with retinopathy in Eastern India: The LVPEI eye and diabetes study. Journal of Ophthalmology, 2016, 3423814.CrossRefGoogle Scholar
- 44.Iype, T., Shaji, S. K., Balakrishnan, A., Charles, D., Varghese, A. A., & Antony, T. P. (2009). Cognition in type 2 diabetes: Association with vascular risk factors, complications of diabetes and depression. Annals of Indian Academy of Neurology, 12(1), 25–27.Google Scholar
- 46.Al-Ghamdi, A. A. (2004). A high prevalence of depression among diabetic patients at a teaching hospital in Western Saudi Arabia. Neurosciences (Riyadh, Saudi Arabia), 9(2), 108–112.Google Scholar
- 47.Ali, N., Jyotsna, V. P., Kumar, N., & Mani, K. (2013). Prevalence of depression among type 2 diabetes compared to healthy non diabetic controls. The Journal of the Association of Physicians of India, 61(9), 619–621.Google Scholar
- 53.Yu, Y., Feng, L., Shao, Y., et al. (2013). Quality of life and emotional change for middle-aged and elderly patients with diabetic retinopathy. International Journal of Ophthalmology, 6(1), 71–74.Google Scholar
- 69.Coulter, A., Entwistle, V. A., Eccles, A., Ryan, S., Shepperd, S., & Perera, R. (2015) Personalised care planning for adults with chronic or long-term health conditions. The Cochrane Database of Systematic Reviews (3):Cd010523. https://doi.org/10.1002/14651858
- 70.Holloway, E. E., Sturrock, B. A., Lamoureux, E. L., Keeffe, J. E., & Rees, G. (2015). Depression screening among older adults attending low-vision rehabilitation and eye-care services: Characteristics of those who screen positive and client acceptability of screening. Australasian Journal on Ageing, 34(4), 229–234.CrossRefGoogle Scholar
- 71.Fenwick, E., Khadka, J., Pesudovs, K., Rees, G., & Lamoureux, E. (2017) Diabetic retinopathy and macular edema quality-of-life item banks: Development and initial evaluation using computerized adaptive testing. Investigative Ophthalmology & Visual Science, 58(14), 6379–6387. https://doi.org/10.1167/iovs.16-20950.Google Scholar
- 77.Lamoureux, E. L., Pallant, J. F., Pesudovs, K., Rees, G., Hassell, J. B., & Keeffe, J. E. (2007). The impact of vision impairment questionnaire: An Assessment of Its domain structure using confirmatory factor analysis and rasch analysis. Investigative Ophthalmology & Visual Science, 48(3), 1001–1006.CrossRefGoogle Scholar
- 80.Grading diabetic retinopathy. (1991). from stereoscopic color fundus photographs–an extension of the modified airlie house classification. ETDRS report number 10. Early treatment diabetic retinopathy study research group. Ophthalmology, 98(5 Suppl), 786–806.Google Scholar
- 81.Fenwick, E. K., Pesudovs, K., Khadka, J., Dirani, M., Rees, G., Wong, T. Y., Lamoureux, E. L. (2012). The impact of diabetic retinopathy on quality of life: Qualitative findings from an item bankdevelopment project. Quality of Life Research, 21(10), 1771–1782.Google Scholar