Advertisement

Experience of Anti-VEGF Treatment and Clinical Levels of Depression and Anxiety in Patients With Wet Age-Related Macular Degeneration

  • Hugo Senra
    Affiliations
    Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
    Search for articles by this author
  • Konstantinos Balaskas
    Affiliations
    Manchester Royal Eye Hospital, Central Manchester Foundation Trust, Manchester, United Kingdom
    Search for articles by this author
  • Neda Mahmoodi
    Affiliations
    Faculty of Health and Social Sciences, School of Psychology, Leeds Beckett University, Leeds, United Kingdom
    Search for articles by this author
  • Tariq Aslam
    Correspondence
    Inquiries to Tariq Aslam, Manchester Royal Eye Hospital, Oxford Road, Manchester M13 9PL, UK
    Affiliations
    Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom

    Manchester Royal Eye Hospital, Central Manchester Foundation Trust, Manchester, United Kingdom
    Search for articles by this author
Published:March 13, 2017DOI:https://doi.org/10.1016/j.ajo.2017.03.005

      Purpose

      To investigate detailed patient experiences specific to receiving vascular endothelial growth factor inhibitors (anti-VEGF) for wet age-related macular degeneration (wAMD), and to acquire a snapshot of the frequency of clinically significant levels of depression, anxiety, and posttraumatic stress among patients and levels of burden in patients' carers.

      Design

      Observational cross-sectional mixed-methods study.

      Methods

      Three hundred patients with wAMD receiving anti-VEGF treatment and 100 patient carers were recruited. Qualitative data on patients' experience of treatment were collected using a structured survey. Standardized validated questionnaires were used to quantify clinically significant levels of anxiety, depression, and posttraumatic stress, as well as cognitive function and carers' burden.

      Results

      Qualitative data showed that 56% of patients (n = 132) reported anxiety related to anti-VEGF treatment. The main sources of anxiety were fear of going blind owing to intravitreal injections and concerns about treatment effectiveness, rather than around pain. From validated questionnaires, 17% of patients (n = 52) showed clinical levels of anxiety and 12% (n = 36) showed clinical levels of depression. Depression levels, but not anxiety, were significantly higher in patients who received up to 3 injections compared with patients who received from 4 to 12 injections (analysis of variance [ANOVA] P = .027) and compared with patients who received more than 12 injections (ANOVA P = .001).

      Conclusions

      Anti-VEGF treatment is often experienced with some anxiety related to treatment, regardless of the number of injections received. Clinical levels of depression seem to be more frequent in patients at early stages of anti-VEGF treatment. Strategies to improve patient experience of treatment and minimize morbidity are suggested.
      To read this article in full you will need to make a payment

      References

        • Coleman H.R.
        • Chan C.C.
        • Ferris 3rd, F.L.
        • Chew E.Y.
        Age-related macular degeneration.
        Lancet. 2008; 372: 1835-1845
        • Wong W.L.
        • Su X.
        • Li X.
        • et al.
        Global prevalence of age-related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis.
        Lancet Glob Health. 2014; 2: e106-e116
        • Solomon S.D.
        • Lindsley K.B.
        • Krzystolik M.G.
        • Vedula S.S.
        • Hawkins B.S.
        Intravitreal bevacizumab versus ranibizumab for treatment of neovascular age-related macular degeneration: findings from a Cochrane Systematic Review.
        Ophthalmology. 2016; 123: 70-77.e1
        • Ba J.
        • Peng R.S.
        • Xu D.
        • et al.
        Intravitreal anti-VEGF injections for treating wet age-related macular degeneration: a systematic review and meta-analysis.
        Drug Des Devel Ther. 2015; 28: 5397-5405
        • Shao J.
        • Choudhary M.M.
        • Schachat A.P.
        Neovascular age-related macular degeneration.
        Dev Ophthalmol. 2016; 55: 125-136
        • Boyle J.
        • Vukicevic M.
        • Koklanis K.
        • Itsiopoulos C.
        Experiences of patients undergoing anti-VEGF treatment for neovascular age-related macular degeneration: a systematic review.
        Psychol Health Med. 2015; 20: 296-310
        • Segal O.
        • Segal-Trivitz Y.
        • Nemet A.Y.
        • Cohen P.
        • Geffen N.
        • Mimousi M.
        Anxiety levels and perceived pain intensity during intravitreal injections.
        Acta Ophthalmol. 2016; 94: 203-204
        • McCloud C.
        • Khadka J.
        • Gilhotra J.S.
        • Pesudoivs K.
        Divergence in the lived experience of people with macular degeneration.
        Optom Vis Sci. 2014; 91: 966-974
        • Senra H.
        • Ali Z.
        • Balaskas K.
        • Aslam T.
        Psychological impact of anti-VEGF treatments for wet macular degeneration-a review.
        Graefes Arch Clin Exp Ophthalmol. 2016; 254: 1873-1880
        • Henriksen K.
        • Adhami S.
        Patient experience of intravitreal injections in AMD.
        International Journal of Ophthalmic Practice. 2010; 1: 68-72
        • Thetford C.
        • Hodge S.
        • Harding S.
        • Taylor S.
        • Knox P.
        Living with age-related macular degeneration treatment: patient experiences of being treated with ranibizumab (Lucentis)® intravitreal injections.
        Br J Vis Impair. 2013; 31: 89-101
        • Blaha G.
        • Tilton E.
        • Barouch F.
        • Marx J.L.
        Randomized trial of anesthetic methods for intravitreal injections.
        Retina. 2011; 31: 535-539
        • LaHood B.
        • Sherwood D.
        • Suter A.
        Comparative assessment of the effectiveness of anaesthesia for intravitreal bevacizumab injection.
        Clin Exp Ophthalmol. 2011; 39: 184-185
        • Moisseiev E.
        • Regenbogen M.
        • Bartfeld Y.
        • Barak A.
        Evaluation of pain in intravitreal bevacizumab injections.
        Curr Eye Res. 2012; 37: 813-817
        • Rifkin L.
        • Schaal S.
        Factors affecting patients' pain intensity during in office intravitreal injection procedure.
        Retina. 2012; 32: 696-700
        • Roth D.
        • Scott I.
        • Gulati N.
        • Prenner J.
        Patient perceptions of discomfort and changes in vision and functional status associated with intravitreal triamcinolone injection.
        Am J Ophthalmol. 2006; 142: 492-494
        • Tailor R.
        • Beasley R.
        • Yang Y.
        • Narendran N.
        Evaluation of patients' experiences at different stages of the intravitreal injection procedure – What can be improved?.
        Clin Ophthalmol. 2011; 5: 1499-1502
        • Chua P.
        • Mitrut I.
        • Armbrecht A.
        • Vani A.
        • Aslam T.
        • Dhillon B.
        Evaluating patient discomfort, anxiety, and fear before and after ranibizumab intravitreous injection for wet age related macular degeneration.
        Arch Ophthalmol. 2009; 127: 939-940
        • Dawson S.R.
        • Mallen C.D.
        • Gouldstone M.B.
        • Yarham R.
        • Mansell G.
        The prevalence of anxiety and depression in people with age-related macular degeneration: a systematic review of observational study data.
        BMC Ophthalmol. 2014; 14: 78
        • Eramudugolla R.
        • Wood J.
        • Anstey K.J.
        Co-morbidity of depression and anxiety in common age-related eye diseases: a population-based study of 662 adults.
        Front Aging Neurosci. 2013; 5: 56
        • Mathew R.S.
        • Delbaere K.
        • Lord S.R.
        • Beaumont P.
        • Vaegan
        • Madigan M.C.
        Depressive symptoms and quality of life in people with age- related macular degeneration.
        Ophthalmic Physiol Opt. 2011; 31: 375-380
        • Casten R.
        • Rovner B.W.
        • Leiby B.E.
        • Tasman W.
        Depression despite anti-vascular endothelial growth factor treatment of age-related macular degeneration.
        Arch Ophthalmol. 2010; 128: 506-508
        • Lee W.J.
        • Cho H.Y.
        • Kim D.H.
        • et al.
        Depression of late age-related macular degeneration patients in Korea.
        Asia Pac J Ophthalmol. 2013; 2: 23-27
        • Sloan F.A.
        • Hanrahan B.W.
        The effects of technological advances on outcomes for elderly persons with exudative age-related macular degeneration.
        JAMA Ophthalmol. 2014; 132: 456-463
        • Gopinath B.
        • Liew G.
        • Burlutsky G.
        • Mitchell P.
        Age-related macular degeneration and 5-year incidence of impaired activities of daily living.
        Maturitas. 2014; 77: 263-266
        • Walker J.G.
        • Anstey K.J.
        • Lord S.R.
        Psychological distress and visual functioning in relation to vision-related disability in older individuals with cataracts.
        Br J Health Psychol. 2006; 11: 303-317
        • Banerjee A.
        • Kumar S.
        • Kulhara P.
        • Gupta A.
        Prevalence of depression and its effect on disability in patients with age-related macular degeneration.
        Indian J Ophthalmol. 2008; 56: 469-474
        • Casten R.
        • Rovner B.
        Depression in age-related macular degeneration.
        J Vis Impair Blind. 2008; 102: 591-599
        • Wulsin L.R.
        • Jacobson A.M.
        • Rand L.I.
        Psychosocial adjustment to advanced proliferative diabetic retinopathy.
        Diabetes Care. 1993; 16: 1061-1066
        • Dreer L.
        • Elliott T.
        • Berry J.
        • et al.
        Cognitive appraisals, distress and disability among persons in low vision rehabilitation.
        Br J Health Psychol. 2008; 13: 449-461
        • Papadopoulos K.
        • Papakonstantinou D.
        • Montgomery A.
        • Solomou A.
        Social support and depression of adults with visual impairments.
        Res Dev Disabil. 2014; 35: 1734-1741
        • Senra H.
        • Vieira C.
        • Nicholls E.
        • Leal I.
        Depression and experience of vision loss in a group of adults at rehabilitation setting: a mixed-methods pilot study.
        J Rehab Res Dev. 2013; 50: 1301-1314
        • Vink D.
        • Aartsen M.J.
        • Schoevers R.A.
        Risk factors for anxiety and depression in the elderly: a review.
        J Affect Disord. 2008; 106: 29-44
        • Casten R.J.
        • Rovner B.W.
        Update on depression and age-related macular degeneration.
        Curr Opin Ophthalmol. 2013; 24: 239-243
        • Varano M.
        • Eter N.
        • Winyard S.
        • Wittrup-Jensen K.U.
        • Navarro R.
        • Heraghty J.
        The emotional and physical impact of wet age-related macular degeneration: findings from the wAMD Patient and Caregiver Survey.
        Clin Ophthalmol. 2016; 3: 257-267
        • Rees G.
        • Tee H.W.
        • Marella M.
        • Fenwick E.
        • Dirani M.
        • Lamoureux E.L.
        Vision-specific distress and depressive symptoms in people with vision impairment.
        Invest Ophthalmol Visual Sci. 2010; 51: 2891-2896
        • Nyman S.R.
        • Gosney M.A.
        • Victor C.R.
        Emotional well-being in people with sight loss.
        Br J Vis Impair. 2010; 28: 175-203
        • Rees G.
        • Ponczek E.
        • Hassell J.B.
        • Keeffe J.
        • Lamoureux E.
        Psychological outcomes following interventions for people with low vision: a systematic review.
        Expert Rev Ophthalmol. 2010; 5: 385-403
        • Holloway E.E.
        • Sturrock B.A.
        • Lamoureux E.L.
        • Keeffe J.E.
        • Rees G.
        Help seeking among vision-impaired adults referred to their GP for depressive symptoms: patient characteristics and outcomes associated with referral uptake.
        Aust J Prim Health. 2015; 21: 169-175
      1. World Health Organization website.
        (Available at) (Accessed January 28, 2016)
        • Zigmond A.
        • Snaith R.
        The Hospital Anxiety and Depression Scale.
        Acta Psychiatr Scand. 1983; 67: 361-370
        • Poole N.
        • Morgan J.
        Validity and reliability of the Hospital Anxiety and Depression Scale in a hypertrophic cardiomyopathy clinic: the HADS in a cardiomyopathy population.
        Gen Hosp Psychiatry. 2006; 28: 55-58
        • Weiss D.
        • Marmar C.
        The Impact of Event Scale-Revised.
        The Guilford Press, New York1997
        • Folstein M.
        • Folstein S.E.
        • McHugh P.R.
        “Mini-Mental State” a practical method for grading the cognitive state of patients for the clinician.
        J Psych Res. 1975; 12: 189-198
        • Crum R.M.
        • Anthony J.C.
        • Bassett S.S.
        • et al.
        Population-based norms for the Mini-Mental State Examination by age and educational level.
        JAMA. 1993; 269: 2386-2391
        • Reinhard S.C.
        • Gubman G.D.
        • Horwitz A.V.
        • Minsky S.
        Burden assessment scale for families of the seriously mentally ill.
        Eval Program Plann. 1994; 17: 261-269
        • Garcia-Perez M.A.
        • Nunez-Anton V.
        Cellwise residual analysis in two-way contingency tables.
        Educ Pychol Meas. 2003; 63: 825-839
        • NICE (2011)
        Common mental health disorders | Guidance and guidelines | NICE.
        (Available at) (Accessed August 25, 2015)
      2. McManus S. Meltzer H. Brugha T. Bebbington P. Jenkins R. Adult Psychiatric Morbidity in England 2007: results of a household survey. NHS Information Centre for Health and Social Care, 2009 (Available at) (Accessed April 22, 2015)
        • Bennion A.E.
        • Shaw R.L.
        • Gibson J.M.
        What do we know about the experience of age related macular degeneration? A systematic review and meta-synthesis of qualitative research.
        Soc Sci Med. 2012; 75: 976-985
        • Nyman S.R.
        • Dibb B.
        • Victor C.R.
        • Gosney M.A.
        Emotional well-being and adjustment to vision loss in later life: a metasynthesis of qualitative studies.
        Disabil Rehabil. 2012; 34: 971-981
        • De Leo D.
        • Hickey P.A.
        • Meneghel G.
        • Cantor C.H.
        Blindness, fear of sight loss, and suicide.
        Psychosomatics. 1999; 40: 339-344
        • Evans J.R.
        • Fletcher A.E.
        • Wormald R.P.
        Depression and anxiety in visually impaired older people.
        Ophthalmology. 2007; 114: 283-288
        • Zhang X.
        • Bullard K.M.
        • Cotch M.F.
        • et al.
        Association between depression and functional vision loss in persons 20 years of age or older in the United States, NHANES 2005-2008.
        JAMA Ophthalmol. 2013; 131: 573-581
        • Ribeiro M.V.
        • Hasten-Reiter Júnior H.N.
        • Ribeiro E.A.
        • Jucá M.J.
        • Barbosa F.T.
        • Sousa-Rodrigues C.F.
        Association between visual impairment and depression in the elderly: a systematic review.
        Arq Bras Oftalmol. 2015; 78: 197-201