How optometry and mental health intersect

After a 20+-year career in optometry, I embarked on a career as a psychotherapist. I realized how fascinated I was at the crossroads of mental health and optometry by seeing patients, and I had the good fortune of working with optometry students as a fourth-year preceptor and in delivering mentoring workshops for them. This experience allowed me to see the importance of basic mental health knowledge for patients and students ODs.

In conducting informal polling at industry meetings, I found that the vast majority of ODs think that they did not receive enough training in this area and would like to learn more.

Why understanding mental health is important to ODs

What follows are 5 reasons why eyecare professions should have more information on identifying mental health conditions:

• ODs are primary-care practitioners treating the whole patient and may be first to notice mental health or other health concerns in patients (like diabetes).

• More patients are taking psychotropic medications, some of which have ocular adverse effects.

• Mental health is a public health crisis in the United States, and there is a growing emphasis on providing integrated care, which includes ODs establishing relationships with mental health professionals.

• The is a need for ODs to better understand their own mental health care.

• These relationshiops offer the opportunity to create a 2-way referral system with mental health practitioners and help ODs better serve their community.

Common mental health conditions ODs will see

ODs should ensure that their intake forms have a place for patients to list their mental health conditions. It is important to be aware of patients’ mental health status.

Anxiety and depression are the 2 most common conditions I see, and many patients will present to OD offices with these conditions. However, it is important for ODs to familiarize themselves with the basics of all common conditions (see box).

A myriad of ocular conditions can cause anxiety and depression, and ODs can help these patients through patient education and by providing resources. The top 3 ocular conditions that come to mind are retinitis pigmentosa (RP), keratoconus (KC), and Sjögren syndrome (SS).

A study with 194 RP patients with 187 matched controls found, stress, depressed mood, and suicidal thoughts were all higher for RP patients versus control with high statistical significance (P <.001).1

A study of 56 patients with KC and 47 age- and gender-matched healthy control subjects found that KC patients showed a statistically significant (P<.001) higher depression scores versus healthy controls.2

Another study of 62 primary SS patients versus age-matched healthy controls showed patients with SS had significantly higher (P<.05) clinical anxiety and clinical depression compared with controls.3

ODs can help patients whose mental health is affected by ocular conditions. Suggest referral to therapy or support groups and offer education and other resources (see box).

Ocular adverse events from psychotropic medications

Many psychotropic medications work on 3 principle neurotransmitters in the brain:serotonin, norepinephrine, and dopamine. Following are some common medications for several common mental health conditions that you may see on your intake form, as well as ocular adverse events.4 Although this is not an exhaustive list, it is helpful to know ocular adverse events for common mental health conditions that present in ODs’ offices.

Anxiety

Benzodiazepines increase the action of y-aminobutyric acid (GABA) and include clonazepam (Klonopin), lorazepam (Ativan), and alprazolam (Xanax). Selective serotonin reuptake inhibitors (SSRIs) include sertraline (Zoloft), bupropion (Wellbutrin), citalopram (Celexa), escitalopram oxalate (Lexapro), fluoxetine (Prozac). Serotonin-norepinephrine reuptake inhibitors (SNRIs) include venlafaxine (Effexor), duloxetine (Cymbalta), buspirone (BuSpar).

Ocular adverse events are rare, mild intermittent blurry vision (mydriasis/cycloplegia) with SSRIs/SNRIs due to anticholinergic effect and increased intraocular pressure (IOP).

Depression

The same SSRIs and SNRIs mentioned above are also used for depressive disorders. In addition, we also have tricyclic antidepressants (TCA) that increase norepinephrine and serotonin and include amitriptyline (Elavil), amoxapine (Asendin), desipramine (Norpramin). Monoamine oxidase inhibitors include phenelzine (Nardil), selegiline (Zelapar), and isocarboxazid (Marplan).

Ocular adverse events are rare and include mild intermittent blurry vision (mydriasis/cycloplegia) with SSRIs/SSNRIs and TCAs due to anticholinergic effect and increased IOP.

Bipolar disorder

Medications for bipolar mania include lithium, carbamazepine (Tegretol), divalproex sodium (Depakote), and oxcarbazepine (Trileptal), which reduce excitatory (dopamine and glutamate) but increase inhibitory (GABA) neurotransmission. Medications for bipolar depression include lurasidone HCl (Latuda), lamotrigine (Lamictal), quetiapine (Seroquel) and olanzapine and fluoxetine (Symbyax). These medications are thought to be mediated through a combination of central dopamine and serotonin receptor antagonism.

An ocular adverse event associated with lithium is increased tear osmolarity.

Attention-deficit/hyperactivity disorder

Central nervous system stimulants speed up brain activity, increasing dopamine and norepinephrine in the brain, and include methylphenidate (Ritalin), methylphenidate HCl (Concerta), dextroamphetamine and amphetamine (Adderall), lisdexamfetamine dimesylate (Vyvance), dexmethylphenidate (Focalin), and modafinil (Provigil).

An ocular adverse event associated with this category of drugs is myokymia.

Eyes as window to mental health

Investigators of a study of 88 patients with schizophrenia and 88 controls noted a range of eye movements, smooth pursuit, fixation stability, and free-viewing tasks over a 9-month period.5 The data set of 298 assessments could discriminate all cases from controls with near-perfect accuracy at 98.3%.

Another study evaluating eye movement behavior observed 18 patients with Alzheimer’s disease (AD) and 40 age-matched controls during sentence reading. In the AD group, visual exploration was less focused, fixations were much longer, and outgoing saccade amplitudes were smaller than those in controls.6 These eye movement measures could provide a user-friendly marker of early disease symptoms and its progression.

ODs are mandated reporters

According to the American Optometric Association (AOA) Standards of Professional Conduct: “Optometrists have the responsibility to identify signs of abuse and neglect in children, dependent adults and elders and to report suspected cases to the appropriate agencies, consistent with state law.”7

Mandated reporting laws vary by state, so it is incumbent upon ODs to be aware of reporting responsibilities in their states. This information can be found on state websites underDepartment of Children and Families, Elder Protective Services, and Disabled Persons Protection Commission.

Macular pigment optical density and cognition

Research shows a connection between macular pigment optical density (MPOD) and cognitive function.8,9 This connection may serve as a potential biomarker for ODs with a test that is short and easy to perform in the office.

MPOD is a measurement of the attenuation of blue light by macular pigment and is linearly related to the amount of lutein and zeaxanthin in the macula over the region where macular pigment is deposited. Lutein and zeaxanthin are carotenoids that the body cannot produce, so they must come from diet or through supplementation. The higher the MPOD, which can be thought of as “internal sunglasses” protecting us from blue light, the better.

In one study, serum lutein and zeaxanthin were measured, and MPOD was assessed in 108 older adults ( 77.6 ± 2.7 years).8 MPOD levels were significantly associated with better global cognition, verbal learning and fluency, recall, processing speed, and perceptual speed, and serum lutein and zeaxanthin were significantly related to only verbal fluency.

In another study, 24 older adult subjects with mild cognitive impairment (MCI) were compared with 24 matched healthy, older adult controls.9 For subjects with MCI, MPOD was broadly related to cognition, including composite score on a mini-mental state exam (P=.02), visual-spatial and constructional abilities (P=.04), language ability (P=.05), attention (P =.03), and repeatable battery for the assessment of neuropsychological status (P =.03).

By comparison, in healthy older adults MPOD was related only to visual-spatial and constructional abilities (P =.04).

This research shows that MPOD is related to cognitive function in older people. Its role as a potential biomarker of cognitive function deserves further study.

ODs’ own mental health

The AOA’s Ethics Forum presented OD burnout as its first case study.10 Titled “The Modern Practice and Optometrist Burnout,” the case study introduced burnout as an ethical dilemma that affects patient care.

It offers 6 major takeaways for ODs to manage stress:

• Manage time efficiently

• Anticipate, prepare for situations at work and home

• Create a financial plan

• Leave work at work

• Care for yourself (self care)

• Find a fellow OD mentor

ODs are humans, too, and considering the stress of working in or running a practice, can benefit from psychotherapy like everyone else. It is also a particularly stressful time to practice optometry in the age of coronavirus disease 2019, so now more than ever, psychotherapy can be helpful. Today there is greater openness and acceptance of therapy and much less stigma than in the past. ODs can consider individual, couple, or group therapy.

I recommend ODs develop a regular practice staff discussion/support group to process topics that may come up and have a safe space to discuss them.

Referral source

As with pediatricians, internists, and ophthalmologists, ODs can develop a 2-way referral system with mental health practitioners in their practice community. Given the intersection of optometry and mental health, do not underestimate the potential to grow a practice by developing a referral relationship with a few mental health providers in the area.

Lastly, ODs have the opportunity to serve their patients and communities by providing education to schools about learning disabilities, which may be related or caused by an ocular condition like refractive error or amblyopia. ODs can also provide resources to offer support for patients with conditions that may cause anxiety and depression.

If nothing else, I hope this article inspires ODs to think about how optometry intersects with mental health and to use this information to further serve their patients and their communities and to help grow their practices.

References

1. Kim S, Shin DW, An AR, et al. Mental health of people with retinitis pigmentosa. Optom Vis Sci. 2013;90(5):488-493. doi:10.1097/OPX.0b013e31828dee0a

2. Moschos MM, Gouliopoulos NS, Kalogeropoulos C, et al. Psychological aspects and depression in patients with symptomatic keratoconus. J Ophthalmol. 2018; 29;2018:7314308. doi:10.1155/2018/7314308

3. Valtýsdóttir ST, Gudbjörnsson B, Lindqvist U, Hällgren R, Hetta J. Anxiety and depression in patients with primary Sjögren's syndrome. J Rheumatol. 2000;27(1):165-169.

4. Minhas B. The mind’s eye: ocular complications of psychotropic medications. Rev Optom. January 15, 2016. Accessed February 11, 2021. https://www.reviewofoptometry.com/article/the-minds-eye-ocular-complications-of-psychotropic-medications

5. Benson PJ, Beedie SA, Shephard E, Giegling I, Rujescu D, St Clair D. Simple viewing tests can detect eye movement abnormalities that distinguish schizophrenia cases from controls with exceptional accuracy. Biol Psychiatry. 2012;72(9):716-724. doi:10.1016/j.biopsych.2012.04.019

6. Fernández G, Laubrock J, Mandolesi P, Colombo O, Agamennoni O. Registering eye movements during reading in Alzheimer's disease: difficulties in predicting upcoming words. J Clin Exp Neuropsychol. 2014;36(3):302-316. doi:10.1080/13803395.2014.892060

7. How to identify signs of abuse. American Optometric Association. October 7, 2019. Accessed Feabruary 11, 2021. https://www.aoa.org/news/clinical-eye-care/health-and-wellness/identify-signs-of-abuse?sso=y

8. Vishwanathan R, Iannaccone A, Scott TM, et al. Macular pigment optical density is related to cognitive function in older people. Age Ageing. 2014;43(2):271-275. doi:10.1093/ageing/aft210

9. Renzi LM, Dengler MJ, Puente A, Miller LS, Hammond BR, Jr. Relationships between macular pigment optical density and cognitive function in unimpaired and mildly cognitively impaired older adults. Neurobiol Aging. 2014;35(7):1695-1699. doi:10.1016/j.neurobiolaging.2013.12.024

10. Physician burnout improving, still high comparatively. American Optometric Association. February 26, 2019. Accessed February 11, 2021. https://www.aoa.org/news/practice-management/perfect-your-practice/physician-burnout-improving-still-high-comparatively?sso=y