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62 EW GLAUCOMA February 2011 October 2012 Managing fear and depression in glaucoma patients by Vanessa Caceres EyeWorld Contributing Writer don't know enough about this issue yet." In his recent work with Dr. Kahook, Brian Yochim, Ph.D., VA Palo Alto Health Care System and Stanford University, Palo Alto, Calif., said the investigators identified a 2006 study published in General Hospital Psychiatry that reported patients with pseudoexfoliative glau- coma had a higher rate of depressive symptoms than control participants. However, a 2002 study from Oph- thalmology found the prevalence of depression to be similar when comparing open-angle glaucoma patients and controls. The recent study from Drs. The glaucoma specialist's role in helping patients cope D epressive symptoms and anxiety are two common, normal responses to a glaucoma diagnosis. However, are glaucoma specialists addressing those fears adequately enough in newly diagnosed patients? "How do you talk to people about an incurable, blinding dis- ease? I think this is a fundamental problem," said Reay Brown, M.D., glaucoma specialist, Atlanta Oph- thalmology Associates, Atlanta. Dr. Brown, who has given talks on the topic of allaying patients' fears about a glaucoma diagnosis, believes this is an area where ophthalmolo- gists can try a little harder. "We sometimes create depression and anxiety where there need not be. If you make the patient depressed, it's a failure in communication," he said. Ophthalmologists might natu- rally think that issues of anxiety and depression connected to a glaucoma diagnosis should be addressed by a mental health specialist. "We tend to focus on the medical diagnosis and put everything else on the side. We're not trained in that area, and we're busy," said Malik Y. Kahook, M.D., professor, Department of Ophthalmology, University of Colorado, Aurora. Plus, medical school doesn't usually discuss the soft skill of how to talk to patients. On the patient's end, the internet will often give inaccurate disease information or take facts out of context. Still, depressed, anxious, or cognitively impaired patients are less likely to adhere to their medication regimen, putting themselves at an even greater risk for complications, Dr. Kahook said. Additionally, you want to quell patients' sometimes irrational fears about the disease. "Anecdotally, I find patients are not depressed but anxious," said Douglas J. Rhee, M.D., assistant professor, Massachu- setts Eye and Ear Infirmary, Harvard Medical School, Boston. "They're afraid of going blind, and this is a relatively asymptomatic disease. It's like waiting to be punched." What the studies show Studies that have examined rates of depression and anxiety in glaucoma patients have mixed results. "A few studies have shown that depression is higher in these patients, but they generally show depression rates are not higher," Dr. Rhee said. "On anx- iety, the results are more 50/50. We Kahook and Yochim, published in the April/May issue of the Journal of Glaucoma, tracked depression, anxi- ety, and cognitive impairment in older patients with glaucoma. Using a sample of 41 glaucoma patients, they found memory impairment in 20% of the sample and impaired executive functioning in 22%. They also found mild to moderate depres- sion symptoms in 12.2% of the participants. Only one patient had significant anxiety. "A depressed patient is less likely to understand instructions or adhere to the regimen. Anxiety and depression get in the way," Dr. Kahook said. "The study demonstrates the importance of screening for depres- sion and memory impairment in older adults and referring to mental health professionals for appropriate evaluation and intervention," Dr. Yochim said. Dr. Yochim is currently research- ing better ways to assess cognitive functioning and symptoms of de- mentia in older adults with visual impairment. He said it is not yet clear if the results shown in the re- cently published study are limited to glaucoma or if they can be general- ized to other causes of vision loss or other medical problems. Another recent study, published in the April issue of Investigative Ophthalmology and Visual Science and led by M.L. Popescu, examined the connection between depression and glaucoma, age-related macular degeneration, and Fuchs' corneal dystrophy, all of which are associ- ated with age progression. The re- searchers found that 25% of the 315 patients studied met the study's cri- teria for depression. "Life space and limited activities due to a fear of falling appeared to mediate the rela- tionship between eye disease and depression," wrote the investigators. 8 ways to help patients cope There are ways that ophthalmolo- gists can help patients decrease de- pressive symptoms or anxiety. It all begins with setting the right tone when speaking with patients, Dr. Brown said. 1. Choose your words care- fully, and deliver a positive mes- sage when possible. "Our words are part of the treatment," he said. Although Dr. Brown obviously ac- knowledges that glaucoma can be a blinding disease, he also will empha- size that with the right compliance, the prognosis is usually good and that there are many promising treat- ments for the future. "I tell them that if they take their drops every day, it's a reminder that this is a blinding, incurable dis- ease—but that's it probably not going to be blinding for them," he said. By delivering a message of hope—one that is truthful but not bleak—you will help patients cope, Dr. Brown said. When Dr. Rhee observes patients becoming anxious, he has a piece of advice. "I'll tell them that to the best of my knowledge, fear and anxiety have never cured a human disease. It's normal to go through the grieving stages, but fixating doesn't help," he said. 2. Control your own anxiety about the disease. "We sometimes betray our own anxiety and pass it back to the patients," Dr. Brown said. He likens it to parenting, when a mother's or father's fear about something is sometimes transmitted onto the children, making them feel anxious. Instead, remember that you have the power to help patients cope better by sticking with matter- of-fact but still hopeful facts about their glaucoma. 3. Tell patients that control- ling glaucoma is a team effort— and that they are part of that teamwork. "The patients' job is to adhere to their regimen so there is less likelihood a functional loss," Dr. Kahook said. By emphasizing this, you give patients a sense of control over the disease. Additionally, explain to patients that physicians,