No one likes getting poked in the eye. So it's not surprising that patients receiving anti-vascular endothelial growth factor (VEGF) injections for neovascular (wet) age-related macular degeneration (AMD) often feel anxiety and depression about the treatment, researchers found.
"Doctors should be vigilant to this finding, which might impair patients' quality of life, and consider measures to detect and address this," wrote Hugo Senra, MD, and colleagues from the University of Manchester, England, in the American Journal of Ophthalmology.
They advocate teaching patients about the high probability of benefits and low risk of harm from the treatment.
Studies have shown a prevalence of depression ranging from 15% to 44% and anxiety ranging from 9% to 30% among patients with AMD. But most of these studies were done before the advent of anti-VEGF treatments.
Few studies have explored the feelings of patients as they face this invasive, if helpful, treatment. Researchers who have examined the question have concluded that anxiety peaks around the administration of the first few injections
Investigating Patients' Concerns
To understand this phenomenon more deeply, Senra and co-authors held a meeting with patients, researchers and healthcare professionals to identify key issues and concerns about anti-VEGF therapy.
Using this input they created a survey and asked 345 patients and 100 caregivers to fill it out. Forty-one refused and four were not eligible because they couldn't communicate with the interviewer.
Of the 300 patients who agreed, 59.7% were women and 72% had received treatment for more than a year. Eighty-five percent had good visual acuity or mild visual impairment. Less than 5% were receiving any psychological or psychiatric support.
Patients generally reported satisfaction with their doctors and care, with the support from their hospitals, and the information they got about the their condition and its treatment.
But 168 patients (56%) reported anxiety related to anti-VEGF treatment. They gave these reasons:
- Fear of blindness caused by the intravitreal injection: 39.3%
- Fear that the disease will progress despite treatment: 37%
- Anticipation experienced while in the waiting room: 34.6%
- Fear of the unknown: 30.0%
- Fear of injection pain: 3.3%
The small number who feared injection pain might be explained by the low level of pain actually experienced. Although 42.3% reported pain, the mean level was 2.4 on a scale of 0 to 100.
Among patients who reported pain while receiving an injection, 33.0% experienced it only during the first injections. Another 43.3% felt pain halfway through their treatment and 23.6% felt it during the last few injections they had received. The proportion who anticipated more pain than they felt was 53.7%.
Mental Health Findings
Hospital Anxiety and Depression Scale (HADS) scores on the survey suggested that 17.3% of the patients had clinical levels of anxiety, and only 9.6% of these were receiving psychological or psychiatric treatment at the time of the interview.
Similarly 12.0% had clinical levels of depression, 8.3% of whom were receiving psychological or psychiatric treatment.
The proportion with impaired cognition according to the Mini-Mental State Examination (MMSE) was 9.7%.
According to responses on the Impact of Event Scale Revised (IES-R), 1% of patients showed symptoms of post-traumatic stress.
On the Burden Assessment Scale (BS), 73% reported little or no burden, 19% mild to moderate burden and 8% moderate to severe burden.
The prevalence of anxiety and depression among these patients were higher than in the general population, and the low rate of treatment suggests that ophthalmology practitioners should focus more attention on their patients' emotional health, Senra and colleagues wrote.
Depression scores were significantly higher in patients who had received three or fewer injections than in patients who had received 4-12 injections (P=0.027) and in comparison with patients who had received more than 12 injections (P=0.001). The researchers speculated that patients might fear blindness soon after their diagnosis, but become more optimistic as their treatment proceeds.
However, there were no significant differences for anxiety scores according to the number of injections. This finding conflicted with previous studies. One possibility could be that the sources of anxiety were related to preconceptions about the treatment.
The researchers suggested that better communication from healthcare professionals and perhaps some counselling might reduce some of these anxieties, particularly those related to the fear of going blind, or the fear of the unknown.
They suggested routinely screening patients for symptoms of anxiety and depression at the clinic.
They acknowledged some limitations of their study. It is cross-sectional, so it couldn't show changes over time. It couldn't identify patients who discontinued treatment, or patients with very good or very poor response to treatment. Also it was unclear why 41 patients declined the request to complete the survey.
Still, the researchers said their study justified longitudinal studies and controlled trials to understand anxiety and depression in patients with wet AMD and develop interventions.
This article originally appeared on our partner's website Ophthalmology Times, which is a part of UBM Medica. (Free registration is required.)
Primary Source
American Journal of Ophthalmology
Source Reference: Senra H, et al. " Experience of anti-VEGF treatment and clinical levels of depression and anxiety in patients with wet age-related macular degeneration" Am J Ophthal 2017; DOI: 10.1016/j.ajo.2017.03.005