The Dry Eye Zone

Rebecca's Blog


Study on dry eye, anxiety and depression: Debunking some common assumptions

Context for the Sicca, Anxiety and Depression Study

When I said “debunking common assumptions” in the blog post title, I wasn’t referring to anything mentioned explicitly in this abstract. I refer only to my own observation of how dry eye patients with depression and anxiety conventionally get treated.

Because let’s face it:

In real life, people with dry eye disease who communicate to their eye doctor (or perhaps even any doctor - including the mental health professionals!) about anxiety or depression are routinely treated as though the anxiety and depression are the problem, rather than the dry eye disease.

I’d be the first to admit that this is a delicate subject, because the fact is, for many people, the mental health impact of dry eye can get to the point where it eclipses the dry eye disease and must be treated in its own right to an extent independent of the eye disease. But the fact that mental health impact of dry eye can reach those proportions doesn’t change the fact that dry eye disease and its ‘sequelae’ were the causes in these cases.

That’s one of the reasons why, for an eye doctor to talk about mental health with their dry eye patients, is such dangerous ground. There is a lot of profoundly negative history to overcome here, and those patients often have every reason to interpret their doctor’s words as dismissive: that they have a serious mental health issue rather than a serious eye issue. We are conditioned to hear the word “psychosomatic” the moment you open your mouth to us about seeking mental health care. This also of course ties in with the persistent failure of the eye professions to attach sufficient importance to dry eye symptom severity (especially in the absence of clinical signs to match). This is one of the reasons I advocate so persistently for frequent use of questionnaires that can assign a number to our symptoms, so that our symptoms get taken into account.

So anyway, for many years, I have felt myself at war with this unspoken, implicit assumption: That dry eye just can’t possibly mess with your head that much by itself unless:

  • you already suffered from anxiety and/or depression, or

  • you are at least predisposed to do so.

In other words, you’re obviously a depressive or anxious “type”. And don’t even get me started on how gender often feeds into that assumption… to say nothing of how those who really do suffer from chronic depression, or in fact any mental illness find that their dry eye is less likely to be taken seriously (these are other topics for another day).

My point… the assumptions are JUST NOT TRUE. Are there people with a long history of depression, who also have dry eye disease? Absolutely. But there’s everyone else too, who don’t. Well, so I believe at any rate, after more than 15 years of ‘anecdotal experience’ in the form of dry eye patients that I have spoken with who so often express what a shock the experience of depression or anxiety was to them in the aftermath of their disease onset. To say nothing of my personal experiences.

So I feel validated by the study below, which, in a nutshell, says:

If you help our eyes, you’ll help our heads.

Only thing I wasn’t crazy about in this study was the dropout rate. 7 out of 45 lost to followup? That’s 15% of a group that was pretty small to begin with. Ouch.

The Correlation Between Dry Eyes, Anxiety and Depression: The Sicca, Anxiety and Depression Study.

Bitar et al, Cornea, April 2019



To determine whether improvement in the severity of dry eye disease (DED) symptoms correlates with improvement in anxiety and depression.


This prospective interventional case series recruited 45 adults with evidence of DED. Patients were administered the University of North Carolina Dry Eye Management Scale (DEMS), Generalized Anxiety Disorder 7-item scale (GAD-7), and Personal Health Questionnaire Depression Scale (PHQ-8) to evaluate the severity of DED symptoms, anxiety, and depression, respectively. Standard of care treatment was provided for patients for 3 to 6 months, followed by re-administration of the DEMS, GAD-7, and PHQ-9 surveys. Statistical analysis was performed to assess the relationships between changes in survey scores.


Participants had a mean age of 65.5 (SD, 13.3) years, and 37 (84.6%) were women. Seven patients were lost to follow-up. DEMS and GAD-7 significantly improved from 5.8 ± 1.8 to 4.6 ± 0.2.2 (P = 0.01) and from 5.6 ± 5.5 to 3.3 ± 4.6 (P = 0.05), respectively. Changes in DEMS correlated with changes in PHQ-8 (ρ = 0.3 P = 0.05), but not with changes in GAD-7 (ρ = 0.2 P = 0.3). Changes in DEMS correlated with changes in both PHQ-8 and GAD-7 in the subgroup of patients without prior depression or anxiety diagnosis (ρ = 0.6, P = 0.002; ρ = 0.4, P = 0.02). A multivariate analysis showed that the relationship between DEMS, PHQ-8, and GAD-7 was independent of a prior diagnosis of depression or anxiety and of the presence of comorbidities.


There is a significant correlation between the severity of DED and symptoms of depression and anxiety. Effective DED treatment could have a positive impact on the symptoms of depression and anxiety.