TL;DR: People with dry eye disease are three times more likely to suffer from depression and anxiety. Dry eye symptoms are irritating, painful, disruptive to mood and sleep and can lead to depression. Depression can cause painful stimuli to feel more painful, creates tear film differences, and is better correlated with dry eye symptoms than dry eye signs.
This week, we’ll be exploring a topic that is perhaps under-discussed in relation to our eye health.
Let’s start with an eye-popping statistic. The prevalence of depression and anxiety is estimated to be three times higher in patients with dry eye disease (DED).
What in the world is going on here?
We are seeing an increase in digital strain and burnout. People are spending more time overworked, seeing their screen time skyrocket, and their ability to disconnect in a digital age more compromised than ever.
If people are able to disconnect, it’s understandable that they might pursue escapism – something to forget the emails, the stressful interactions at work: something mindless. Streaming, social media, and other digital avenues are delaying our bedtimes, not helping us feel any better. Our eyes and minds are being stressed in unnatural ways.
But where does the connection between depression and dry eyes come from?
Dry Eyes → Depression
Let’s start with the obvious. Chronic dry eye or digital eye strain symptoms are not comfortable. The persistent discomfort and eye pain can negatively affect mood, sleep, cognitive processes, and mental health.
Moreover, patients with DED more frequently report experiencing chronic pain syndrome, worse dry eye symptoms, and worse ocular and nonocular pain scores.
To clarify: yes, dry eye patients have higher sensitivity to pain even in non-ocular sites (like their forearm, for example).
One study of women in the UK found that dry eye was significantly associated with depression, pelvic pain, and chronic widespread pain syndrome.
DED can also negatively impact visual performance and perception.
Anyone with chronically dry eyes will probably tell you that it’s disrupted their day-to-day activities at least once, if not regularly.
This quality of life disruption isn’t just a one-off occurrence either: dry eye symptoms can negatively impact people’s performance of daily activities, their ability to work, and their emotional well-being.
All of these factors together can lead to worsening mental health conditions. As such, it is more important than ever for optometrists and ophthalmologists to consider comorbidities, including depression and anxiety.
Depression → Dry Eyes
It’s clear DED-related symptoms can lead to or worsen depression and other mental health conditions. However, the directionality of this interaction isn’t as clear cut.
People with depression and anxiety can experience central sensitization. That is, painful stimuli feel more painful. Consequently, they feel more irritation from eye dryness, which can exacerbate their depression and anxiety.
People with depression also have significantly higher levels of markers of inflammation in their tears, which can exacerbate dry eye symptoms.
This highlights an emerging trend in the literature: Depression is more closely associated with dry eye symptoms than with dry eye signs.
Depression scores were found to be correlated with the Ocular Surface Disease Index (OSDI; a very well validated measure of dry eyes), but were not correlated with age, sex, household income, or a variety of eye exam tests.
In fact, subjective happiness may have a greater influence on DED symptoms than do ocular findings. Psychological factors may therefore be key in diagnosing and treating DED.
Fluctuating presentations of dry eye and dry eye symptoms may also be explained by mental health disorders.
That is, appropriate screening and referral to a psychiatrist may be the key to managing patients whose symptoms do not always correlate with objective evidence of dry eye disease.
A Multi-Directional Relationship
A recent publication focused on the COVID-19 pandemic found that subjective dry eye symptoms were related to both depression and anxiety.
I would be remiss not to mention the role of sleep in all of this. Poor sleep quality and dry eye are bidirectionally related. Even one night of sleep deprivation can produce noticeable changes in tear film break-up time, tear osmolarity, and tear secretion.
Factor in the multi-directional relationships between dry eye, poor sleep, and depression, where each can exacerbate symptoms of the other, and the picture comes much more into view. We need to be addressing more facets of wellbeing, and not treating any of them as though they occur in a vacuum.
The flip side of this is encouraging: Treating any of these conditions can often lead to improvements in others. For instance, providing some education around sleep while treating dry eyes improved measures of both sleep and depression.
In sum, it is now obvious that we need to be paying more attention to overall wellness, and not just dry eye symptoms or other conditions by themselves. Symptoms may fluctuate, and may in fact correlate better with mental health, mood, or sleep issues.
At Umay, we have been inspired by this wealth of literature, and want to empower users and our partner clinics alike to consider health more holistically. We look at dry eyes as one of the symptoms under the umbrella of digital eye strain (with sleep and mental health even more broadly under “digital strain”).
Emphasize how dry eyes may be affecting sleep, and how sleep may be affecting mood, how mood may affect productivity or outlook, and how all of these factors can lead to symptoms of depression or anxiety.
Intentionally taking breaks to rest both our eyes and our minds is paramount. REST is designed to be as convenient as possible to use, and can act as a physical reminder to engage in healthier routines – for better eye health, sleep, and mental health.