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Psychology & Health
ISSN: 0887-0446 (Print) 1476-8321 (Online) Journal homepage: http://www.tandfonline.com/loi/gpsh20
Psycho-ophthalmology: Contributions of Health
psychology to the assessment and treatment of
glaucoma
Jorge Luis Méndez-Ulrich & Antoni Sanz
To cite this article: Jorge Luis Méndez-Ulrich & Antoni Sanz (2016): Psycho-ophthalmology:
Contributions of Health psychology to the assessment and treatment of glaucoma, Psychology
& Health, DOI: 10.1080/08870446.2016.1268690
To link to this article: http://dx.doi.org/10.1080/08870446.2016.1268690
Published online: 22 Dec 2016.
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Psycho-ophthalmology: Contributions of Health psychology to the
assessment and treatment of glaucoma
Jorge Luis Méndez-Ulrich and Antoni Sanz*
Faculty of Psychology, Research Group on Stress and Health, Department of Basic,
Developmental and Educational Psychology, Universitat Autònoma de Barcelona, Catalonia,
Spain
(Received 24 March 2016; accepted 17 November 2016)
Background: Asymptomatic in its early stages, glaucoma is the second
leading cause of blindness worldwide. While psychosocial factors are taken
into consideration for a host of diseases such as cancer, heart disease and
autoimmune conditions, to date, psychological issues have been ignored in the
clinical management of glaucoma.
Objective: This work reviews the most relevant contributions from a health
psychology perspective for the assessment and treatment of glaucoma, which
is emerging in the field of psycho-ophthalmology.
Method: To provide scientific evidence regarding contributions of psychology
to the comprehension of glaucoma, a bibliographic review of three databases
(Psicodoc, PsycInfo and Medline) was conducted, spanning the period
between 1940 and 2016.
Results: This review yielded a total of 66 studies published in the period anal-
ysed and identified three areas where health psychology has made substantive
contributions to glaucoma screening, monitoring and treatment: the emotional
impact on patients suffering from glaucoma, the adherence to treatment and
the effects of stress on intraocular pressure.
Conclusions: A health psychology approach for research and therapy of
glaucoma must focus on the management of the negative affect associated
with the diagnosis, the optimisation of treatment adherence and the stress
management of the intraocular pressure measurements.
Keywords: intraocular pressure; glaucoma; stress; adherence; anxiety;
depression
What is glaucoma?
Glaucoma is an ophthalmic disease that has become one of the major causes of
avoidable blindness in the world (Wilson et al., 2002). Given the high prevalence and
chronicity of glaucoma (Antón et al., 2004), it poses an economic burden for public
health and welfare systems (Neymark, Buchholz, Honrubia, & Kobelt, 2008). This
disease leads to irreversible vision loss from damage to the nerve fibres of the optic
nerve. This damage is usually caused by an increase (sudden or progressive) in the
intraocular pressure (IOP; Hall & Guyton, 2015). Nevertheless, glaucoma can also
*Corresponding author. Email: antonio.sanz@uab.cat
© 2016 Informa UK Limited, trading as Taylor & Francis Group
Psychology & Health, 2016
http://dx.doi.org/10.1080/08870446.2016.1268690
affect individuals with normal intraocular pressure. To date, no effective curative treat-
ment for glaucoma has been found. Therapeutic approach to this disease essentially
consists of pharmaceutical management with the purpose of controlling and lowering
IOP levels (Tuulonen et al., 2003), and surgical intervention can be undertaken when
topical therapy fails to halt progression of the disease. Moreover, medications are com-
monly associated with local complications that can compromise adherence to treatment
(keratitis, corneal erosion, pigmentation of the iris, abnormal growth of eye lashes and
conjunctival allergies) and to several systemic adverse reactions as well ( bradycardia,
hypotension, arrhythmias or even asthma; Inoue, 2014).
IOP is, at the same time, the main risk factor, the prime diagnostic indicator and the
sole parameter susceptible to drug management; therefore, reliable measurement of IOP
is crucial to prevent the progression of glaucoma. An understanding of all factors that
might influence physiologic mechanisms, whether cognitive or behavioural, would
promote visual health.
What is health psychology?
Why approach glaucoma from the health psychology perspective?
Since the establishment of Division 38 of the American Psychological Association
(APA) in 1978, and drawing from the definition proposed by Matarazzo (1982), health
psychology has experienced a constant expansion and consolidation, with regard to
research and therapeutic intervention focused on the psychophysiological, affective,
behavioural and social aspects of diseases such as cancer (Fawzy, 1999; Maguire, 2000;
Owen, Klapow, Hicken, & Turner, 2001), infectious and contagious diseases (Cruess
et al., 1999) and cardiovascular pathologies (Herrmann, Brand-Driehorst, Buss, &
Rüger, 2000; Mittleman et al., 1995). According to Matarazzo (1982),
Health psychology is the aggregate of the specific educational, scientific and professional
contributions of the discipline of psychology to the promotion and maintenance of health,
the prevention and treatment of illness, the identification of diagnostic and etiologic corre-
lates of health, illness and related dysfunction, and the analysis and improvement of the
healthcare system and health policy formation. (1982)
However, to date, health psychology has broadly focused neither on the psychosocial
determinants of visual illnesses nor on the role that the health psychologists could per-
form in their treatment. With the aim of identifying the empiric evidence that has been
published up to date in the field of psychology applied to the study and treatment of
glaucoma, we reviewed the literature published between 1940 and 2016. Three main
databases (Medline, Psychinfo and Psicodoc) were analysed. A literature search identi-
fied three fundamental areas of psychological research and intervention in glaucoma,
which constitute the so-called Psycho-ophthalmology field (Rajsekar, Rajsekar, &
Chaturvedi, 1990). These three areas are: the affective impact of glaucoma, the
adherence to treatment and the psychophysiological reactivity of intraocular pressure.
A literature search in each of these three areas was conducted both in English and
Spanish. Keywords used to search those studies related to the emotional effects of glau-
coma were: glaucoma [and] anxiety [and/or] depression [and/or] emotion. Keywords
used for the bibliographical search related to adherence to glaucoma treatment were:
2J.L. Méndez-Ulrich and A. Sanz
adherence [or] compliance [and] depression [and/or] anxiety [and] glaucoma. Finally,
keywords used to search articles focusing on the psychological and psychophysiological
aspects of glaucoma were: psychosocial stress [or] psychological stress [or] cognitive
behavio(u)ral stress [and] intraocular pressure [or] glaucoma, and their equivalents in
Spanish.
The overall results of the search, grouped per fields, are presented in Table 1. In the
sections to follow, critical analyses of the literature found in each of these three areas
are presented. Finally, an interactive and integrative model for the study and approach
of the psychological components of glaucoma is offered in the last section of this work.
Affective impact of glaucoma
The diagnosis of glaucoma confronts the patient with a health issue that is usually
chronic. Of greater significance, glaucoma implies a risk of permanent vision loss,
which can be experienced as a threat to the patient’s integrity, health and quality of life.
Several studies relate how a glaucoma diagnosis is associated with an increase in anxi-
ety, stress and depression (Agorastos et al., 2013; Blumen-Ohana, Akesbi, Laplace, &
Nordmann, 2014; Dawodu, Otakpor, & Upoknman, 2004; Fasih, Hamirani, Jafri, Riaz,
& Shaikh, 2010; Ginies, 2009; Hamelin et al., 2002; Kong, Yan, Sun, & Xiao, 2015;
Mabuchi et al., 2012). We take into account the sample size and the use of validated
instruments for measuring anxiety and depression as criteria for rating the quality of
these studies and ordering them in the further description.
Mabuchi et al. (2008) used the Hospital Anxiety and Depression Scale (HADS;
Zigmond & Snaith, 1983) to assess anxiety state and depression and they found signifi-
cant differences between a group of participants suffering from glaucoma (n= 230) and
a control group (n= 230). In this study, 13% of the participants suffering from glau-
coma experienced elevated levels of anxiety, compared to 7% observed in the control
group (p= .03). Similarly, prevalence of depression was 11% for patients with
glaucoma, while only 5% for the control group (p= .03). El-Mogy, El-Hadidy, and
El-Kaneshy (2014) found a prevalence of 45 and 54% in mood and anxiety disorders,
respectively (n= 384).
Tastan, Iyigun, Bayer, and Acikel (2010) also obtained evidence in relation to the
impact of a glaucoma diagnosis on the patient’s emotional state in a study that included
121 patients suffering from glaucoma and 64 participants in the control group. With
regard to emotional distress, prevalence of anxiety symptoms (assessed with the HADS
scale) was 14%. In addition, depressive symptomatology (clinical or subclinical) was
found in 57% of patients diagnosed with glaucoma. In contrast, in the control group,
only two participants were categorised as having anxiety (χ
2
= 4.30, p= .001;), and six
Table 1. Results of the bibliographic search. Sources: Medline, Psychinfo and Psicodoc
databases.
Total amount of scientific articles Publication period
Affective impact of glaucoma 40 1940–2015
Adherence to treatment 14 2004–2015
Psychophysiological reactivity 12 1996–2015
Psychology & Health 3
as having depression (χ
2
= 37.5, p= .001). This study emphasised the importance of
assessing the quality of life and the emotional state of patients suffering from glaucoma,
with the aim of providing them with sufficient health services, including the psychoso-
cial support along with conventional medical treatment. One additional finding under-
scores the need for the inclusion of psychosocial interventions as a social support: the
risk of depression is 2.94 times higher in unmarried persons when compared to those
who were married (Tastan et al., 2010).
Another study (Ha, Chang, & Lee, 2002) compared the levels of the anxiety state
using the State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Lushene, Vagg, &
Jacobs, 1983) and of depression using the Beck Depression Inventory (BDI
®
; Beck,
Ward, Mendelson, Mock, & Erbaugh, 1961) between patients suffering from glaucoma,
cataracts and healthy controls (n= 25 in all the groups). Differences were found to
reach statistical and clinical significance both for anxiety and depression among patients
diagnosed with glaucoma, when compared to the cataract and control groups (Table 2).
Threats of chronicity of disease as well as of permanent visual loss could explain such
results.
Multiple studies emphasise an association between anxiety and depression and the
diagnosis of glaucoma. Tan, Shao, and Liu (2013) concluded that the prevalence of
anxiety, depression and comorbidity of anxiety and depression disorders in a sample of
60 patients with open-angle glaucoma was, respectively, 33, 27 and 13%. Consistently,
in studies evaluating the quality of life and the emotional status of 508 glaucoma
patients, a remarkable prevalence for depression (23%) and anxiety disorders (16%)
was found (Zhou, Qian, Wu, & Qiu, 2013,2014). More recently, Ma, Shen, Qi, and
Sun (2015) have identified a greater prevalence of affective disorders (53 vs. 26%,
χ
2
= 21.91; p< .0001) and anxiety disorders (50 vs. 22%, χ
2
= 30.27; p< .0001) in a
sample of 120 glaucoma patients when compared to matched healthy controls. This
study also found an odds-ratio of 3.0 in the prevalence of sleeping disorders (54%) in
glaucoma patients when compared to a control group (18%). Kong, Zhu, Hong, and
Sun (2014) found that the prevalence of anxiety and depressive disorders was higher in
angle-closure glaucoma patients compared to open-angle glaucoma patients (p= .002
for anxiety and p= .03 for depression), and to a control sample ( p< .001 for both dis-
orders). In addition, both groups showed higher ratings both for anxiety and depression
when compared to a healthy control group. Furthermore, Skalicky and Goldberg (2008)
found a positive correlation between the severity of the disease and the symptoms of
depression in a group of patients suffering from glaucoma (p= .02). For the same
group, negative correlation with quality of life was found for severity of disease.
As stated, strong empirical evidence underscores the affective impact of the diagno-
sis of glaucoma and this justifies attention to psychosocial factors as a priority objective
in the treatment of such patients. Congruently, some studies inform of the benefits that
Table 2. Mean and confidence intervals for anxiety and depression (Ha et al., 2002). STAI-
S = State and trait anxiety inventory-state; BDI = Beck depression inventory®.
STAI-S BDI
Glaucoma group 44.8 [31.12–58.44] 15.7 [5.56–25.88]
Cataract group 34.6 [25.47–43.81] 8.4 [1.64–15.2]
Control group 35.6 [28.26–42.86] 8.8 [3.884–13.68]
4J.L. Méndez-Ulrich and A. Sanz
glaucoma patients may gain from psychological therapies for different situations, related
to their disease. For instance, patients who undergo surgery were trained with relaxation
techniques as a part of their pre and postoperative management (Shousen & Ningyu,
2004).
It is worthwhile to highlight the study conducted by Lim et al. (2007), which looks
at alternative areas to approach and study glaucoma from a clinical perspective. The
authors administered the Minnesota Multiphasic Personality Inventory (MMPI-2
®
; Ben-
Porath & Tellegen, 2008) to investigate a sample of 56 glaucoma patients and 52
healthy controls. The results suggest a possible relationship between some personality
dimensions and glaucoma. It was noted that patients suffering from glaucoma scored
above average from the general population when evaluated for hypochondria
(p= .008), hysteria (p= .006) and health care concerns ( p= .003). Does it mean that
personality traits could account for the psychological adaptation to glaucoma? In this
sense, Bubella, Bubella, and Cillino (2014) emphasise the importance of further investi-
gation regarding the potential role of personality traits in the occurrence of glaucoma.
Their study included 50 patients with open-angle glaucoma, 64% of them showing a
type-A behaviour pattern, and a relationship between the level of visual field affectation
and the score in anxiety.
To conclude, a recent bibliographic review carried by McCusker and Koola (2015)
on the prevalence of depression related to ophthalmic diseases recognises the strong
relationship between these illnesses, which suggests the importance of collaborative
work between physicians and mental health professionals.
Adherence to treatment in glaucoma
The standard medical treatment of glaucoma consists of instilling one or more topical
eye drops to reduce the IOP (Tuulonen et al., 2003). The literature published on the
assessment of glaucoma patient’s adherence to therapy shows great variability, from 23
to 60%, depending upon the criterion used as an operational definition. As in other
fields, no single criterion exists to measure adherence to treatment in patients suffering
from glaucoma (Olthoff, Schouten, Vandeborne, & Webers, 2005). Among those more
commonly cited in the scientific literature, the most restrictive criterion considers adher-
ence to treatment to be poor when patients forget one dose of drug/s at least once a
month (Vincent, 1972), while the criterion most frequently used for research in ophthal-
mology establishes non-compliance when patients forget one or two doses per week
(Bloch, Rosenthal, Friedman, & Caldarolla, 1977; Konstas, Maskaleris, Gratsonidis, &
Sardelli, 2000). Deokule, Sadiq, and Shah (2004) established different degrees of non-
compliance depending on the number of missed doses in the two-week period prior to
evaluation (one, two or more than two missed doses).
In an extensive meta-analysis, DiMatteo, Lepper, and Croghan (2000) suggested that
the risk to fail in following medical prescriptions for patients suffering from a broad
spectrum of conditions (from cancer to kidney transplantation) is tripled in patients with
greater depressive symptomatology (95% confidence interval 1.96–4.89). As discussed
in the previous section, the prevalence of depressive symptomatology is elevated in
glaucoma patients, and this could be related to their poor adherence to treatment. This
hypothesis relies on outcomes obtained in studies such as that conducted by Jayawant,
Bhosle, Anderson, and Balkrishnan (2007), performed on a retrospective cohort study
Psychology & Health 5
with a sample of 268 glaucoma patients. The authors reported that depressive
symptomatology was greater in patients who did not follow the pharmaceutical
treatment protocol as prescribed (p< .01); however, it was not possible to determine
causality or just a simple correlation between depression and adherence to treatment.
Pappa et al. (2006) also obtained empirical evidence of this potential association
between depression and adherence in a sample of 100 glaucoma patients. In order to
measure depression symptoms, the authors used a battery of tests including the CES-D
(Center for Epidemiologic Studies Scale), the GHQ-28 subscale of depressive feelings
(General Health Questionnaire-28) and the SCL-90-R (Symptoms Checklist 90-R).
Forty-two per cent of patients with glaucoma were classified as ‘non-compliers’, those
who omitted more than two doses per week. Non-compliers presented more severe
symptoms of glaucoma. Depression was found to be associated with poor compliance,
whereas adoption of immature defensive style further increased the risk for non-compli-
ance with glaucoma treatment. The results of this study are summarised in Table 3.
In addition, a study conducted by Yochim, Mueller, Kane, and Kahook (2012) not
only suggests an association between depressive symptomatology and poor adherence
to treatment, but also focuses on cognitive impairment ( loss of memory and other
executive functions) as a possible key factor in determining adherence to treatment.
Cognitive impairment is a pertinent measure considering the advanced mean age of
patients suffering from glaucoma.
Roland, Chang, Frazier, Plyler, and Friedman (2014) observed 14.2% of patients
suffering from glaucoma in a sample (n= 491) were non-adherent to drug treatment
(p< .05). Similar to other studies cited, this group also showed greater psychopatholog-
ical morbidity and more elevated levels of depression than the adherent patients, but
this group differed in that non-adherent patients were younger. Similar results have been
obtained by Sleath, Blalock, Muir, Carpenter, and Lawrence (2014), in a multicenter
study carried out in six hospitals (n= 228): a significant correlation between compliance
with glaucoma medications and depressive symptoms was found (p= .02). Kong et al.
(2014 also identified in a cross-sectorial, hospital-based study, a negative correlation
among depression levels and compliance with medication instructions in 508 glaucoma
patients (p< .001).
Since the therapeutic approach to glaucoma involves control of IOP through
pharmaceutical management often using a combination of drugs, further study of the
psychological variables that potentially determine patient adherence is warranted to
improve compliance.
Table 3. Summary of the outcomes of the study conducted by Pappa et al. (2006). CES-D =
Center for epidemiologic studies scale; GHQ-28 = General health questionnaire; SCL-90-
R = Symptom checklist 90-R.
Measure Groups Scores (mean) pvalue
CES-D Adherents 22.2 .05
Non-adherents 25.8
GHQ-28 (Depression scale) Adherents 9.4 .02
Non-adherents 11.0
SCL-90-R (Depression scale) Adherents 1.0 .05
Non-adherents 1.4
6J.L. Méndez-Ulrich and A. Sanz
Psychophysiological reactivity and white coat ocular hypertension
Despite a paucity of research focused on the psychophysiology of IOP, some studies
provide substantial evidence to support the hypothesis that IOP reacts to different cogni-
tive stressors, which may increase IOP to a clinically significant degree, from 1.3 to
2.6 mmHg (Brody, Erb, Veit, & Rau, 1999; Erb, Brody, & Rau, 1998; Kaluza, Strem-
pel, & Maurer, 1996; Leung, Yap, & Siu, 1999; Méndez-Ulrich, Casas, & Sanz, 2013;
Méndez-Ulrich & Sanz, 2016; Sauerborn, Schmitz, Franzen, & Florin, 1992; Stan, Tirz-
iu, & Lupascu, 2011). The physiological basis of such reactivity could lie in the sympa-
thetic and/or parasympathetic regulation of aqueous humor dynamics (production and
drainage, respectively), upon which IOP values depend (Chiquet & Denis, 2004;
Gherezghiher, Hey, & Koss, 1990; Méndez-Ulrich & Sanz, 2016). Ventura (2009)
hypothesise that psychosocial stress may impact glaucoma through different pathways:
(1) psychological stress induces the sympathetic adrenomedullar axis (SAM) to release
catecholamines, which cause vasospasm that could impair the axonal function of retinal
ganglion cells; (2) chronic stress triggers an overdrive of the hypothalamic–pituitary–
adrenal (HPA) axis and elevates the level of glucocorticoids systemically and, more
specifically, at the trabecular meshwork, which could increase resistance to the aqueous
humor drainage; and (3) emotional stressors are known to increase inflammation and
cytokines, like TNF-α, that may damage retinal ganglion cells. Chronic psychosocial
stress is related to higher IOP levels according to Yamamoto et al. (2008), and Doshi,
Ying-Lai, Azen, and Varma (2008), although these are preliminary studies. Major
literature findings in the field of inducing IOP reactivity are summarised in Table 4.
Although the effect of psychophysiological reactivity on the development or progres-
sion of glaucoma remains unclear, one study suggested that IOP reactivity related to anxi-
ety could compromise the validity of IOP measurements when obtained in an
ophthalmological clinical setting (Méndez-Ulrich et al., 2013). These results led the
authors to describe a hypothetical phenomenon analogous to the white coat syndrome for
systemic hypertension and named it white coat ocular hypertension, which could be influ-
enced by the perception of control and threat experienced by the patient during IOP mea-
surement (MacDonald, Laing, Wilson, & Wilson, 1999; Ogedegbe et al., 2008; Pickering,
Gerin, & Schwartz, 2002; Verdecchia, Staessen, White, Imai, & O’Brien, 2002). In the
study of Méndez-Ulrich and Sanz (2016), conducted in a simulated clinical context, a
relationship between the anxiety state, heart rate and IOP was found, and the effect of anx-
iety on increasing the IOP was clinically significant (+2.64 mmHg). A similar response to
stress occurs with blood pressure measurement (Enström, Pennert, & Lindholm, 2000).
The characterisation of the white coat ocular hypertension may be a finding of clinical
Table 4. Summary of the major findings in psychophysiology of intraocular pressure.
Study Sample Stressor Reactivity pvalue
Kaluza and
Maurer
(1997)
22 glaucoma patients Mathematical + distracters +1.5 mmHg <.0001
Brody et al.
(1999)
49 healthy subjects Mathematical +1.7 mmHg <.0001
Sauerborn al.
(1992)
19 near-sighted subjects
19 healthy subjects
Mathematical +1.3 mmHg <.0001
Psychology & Health 7
relevance since an increase in peripheral arousal induced by certain contextual variables
that are implicit to the health care environment and considered stressful by patients could
induce artificially elevated measurements that would yield an overestimation of the IOP,
which could possibly result in an over-diagnosis (due to false positives) by clinicians.
A health psychology model for glaucoma
As previously mentioned, studies included in this critical review have identified three
main areas for psychosocial research and intervention for patients suffering from glau-
coma (Figure 1). Relevant for the improvement of health and quality of life and comple-
mentary to medical treatment, these three areas are: (1) management of the negative affect
associated with the diagnosis of glaucoma, (2) assessment and optimisation of treatment
adherence and (3) stress management within the clinical setting where intraocular pres-
sure measurements are obtained. These areas of intervention influence one another. Treat-
ment of glaucoma from the health psychology perspective requires a broadened,
integrative, biopsychosocial approach as opposed to a narrow, simplistic analysis focused
on occasional and isolated psychotherapeutic interventions applied sporadically when
problems with any of the critical issues previously mentioned arise. In this sense, some
studies, such as the one conducted by Kong and Sun (2015), suggest the effectiveness of
educational activities designed to reduce the prevalence of affective disorders (anxiety or
depression), and would improve adherence to treatment, given the follow-up and constant
support provided by a collaboration of health care professionals with health psycholo-
gists. A recent study by Bertelmann and Strempel (2015) suggests that a relaxation inter-
vention in combination with glaucoma drug therapy leads to better corrected visual
acuity, lower levels of IOP and an improved general mental state in the short term. Fur-
thermore, physical activity adapted to the patient’s ability could reinforce the efficacy of
treatment, given its potential positive effect on IOP (Marc & Stan, 2013).
With the high prevalence of mood disorders in glaucoma patients, the association
between a patient’s emotional status and their compliance with medical treatment is
considered. When glaucoma patients are found to have a mood disorder, it is useful to
examine the potential impact on treatment adherence, in an effort to optimise
Figure 1. Interactive model of the main topics that could be addressed by psycho-ophthalmology
from a biopsychosocial perspective of glaucoma.
8J.L. Méndez-Ulrich and A. Sanz
compliance through evidence-based effective interventions adapted to the patients’
needs, traits and capabilities. On the other hand, poor adherence to treatment may indi-
cate an underlying affective disorder, which could undermine the patient’s quality of life
and disease outcome. Moreover, the affective state of these patients may depend, to a
great extent, on the subjective assessment of their own health status. A patient’s altered
affect coupled with the clinician’s mere presence may be perceived by the patient as an
invasion of personal space and could induce anxiety in the moment the IOP is mea-
sured. In some cases, such stress could induce an overestimation of the IOP measure-
ment obtained in the clinical context, through an effect known as white coat ocular
hypertension. Over-diagnosis reinforces negative mood, thereby establishing a vicious
downward spiral that negatively impacts the patient’s well-being.
This model justifies the need to integrate the health psychologist into the medical team
to better understand the biopsychosocial aspects of glaucoma, and to help the patient to con-
front and manage this condition more efficiently. Future research should be approached from
an integrative perspective to study the complex interactions at play among the biological,
psychological and social aspects of glaucoma to better understand its pathophysiology and
treatment. In that sense, we consider as critical issues to be elucidated in the future: (1) to
assess whether the effectiveness of antidepressant therapies is linked to an increase in com-
pliance with glaucoma medication in non-compliant patients, (2) to make clear the possible
role of anxiety and depression as independent risk factors for glaucoma and (3) to confirm
the purported phenomenon of white coat ocular hypertension.
Acknowledgements
We thank Cèlia Batlle Massagué for the linguistic revision of this manuscript.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This work was supported by the Ministry of Education, Culture and Sport, Government of Spain
[grant number SEJ2006-12418/PSIC].
ORCID
Jorge Luis Méndez-Ulrich http://orcid.org/0000-0001-9718-0607
Antoni Sanz http://orcid.org/0000-0002-7952-4477
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