Depression and Loneliness in Diabetic Macular Edema Patients as they Carryout Daily Visual and other Life Tasks

1Hina Sultan Department of Applied Psychology, Lahore College for Women University

Email address: hina.sultan91@yahoo.com 2Ghulam Ishaq Department of Psychology, Lahore Leads University Email address: ghulam.ishaq@leads.edu.pk 3Muhammad Ali

Department of Psychology, Government Colleg Email address: Muhammadali11660@gmail.com

Background. Diabetes Prevalence Survey of Pakistan (2017) reported 17% of people (approximately 27 million) living in Pakistan suffer from Diabetes mellitus (either Type I or Type II); aged 20 and above (Basit, Fawwad, Qureshi, & Shera, 2018). Health care professionals predict high-risk of Diabetic Macular Edema when HbA1c levels rise over 6.5% (range 8-11%) in any diabetic patient, which can cause blurred or wavy vision, and gradual loss of central vision causing complete blindness, making patients dependent on others. So, it is the need of hour to spread awareness regarding this complicated issue among people. Objectives. To examine how many Diabetic Macular Edema patients report difficulties in performing a variety of daily life tasks. To investigate vision tasks dependence with depression and loneliness.

Method Sample

Using purposive sampling technique, 300 (N = 300) Diabetic Macular Edema (DME) patients visiting public Hospitals for treatment, were selected. However, 14 patients left the study and did not complete the study survey due to limited time, thus the final sample consisted of 286 patients (total 572 eyes), including early adulthood (n=112), middle adulthood (n=66) and late adulthood (n=108), aged between 20-70 years. Type I and Type II DM patients with macular edema in both eyes with visual acuity lower than 6/6 were included. Visual acuity test (Snellen Chart) revealed that patients were unable to see largest image on the chart with one eye (completely blind), however with the help of second eye they were able to read large size letters, i.e., first three rows on the chart, but not the last three rows, or were able to read them with difficultly; some patients could just saw the images (animal pictures). The average retinal thickness of patients was 293.1 µm (normal range at macula: 150-320 µm) which was at higher end of the range. Further, Optical Coherence Tomography (OCT) showed when there was extensive DME in one eye the other was also infected (40-70%). Patients were having visual difficulties even with contact lenses and glasses (partially blind). We excluded patients with physical complications like arthritis, renal malfunctioning, paralysis, physical, reading, and learning disabilities.

Measures Daily Living Tasks Dependent on Vision Scale: This scale comprised of 22 items covering five different tasks that were dependent on visual abilities; 6 items (e.g. ability to cut food, cut nails, use kitchen appliances etc.) represented distance acuity (DA), 6 items (e.g. distinguishing facial features of a person across room or street etc.) for near acuity (NA), 2 items for light-dark adaptation (LDA), 4 items for reading comprehension (RC) and 2 for walking around (WA). Each item was measured on a 4-point Likert-type scale with 4 (no difficulty at all), 3 (a little difficulty), 2 (a lot of difficulty) to 1 (cannot see to do). Composite score for each task could be calculated to assess different tasks associated with visual functions (Schmier, Halpern & Covert, 2006). In the current study, the reliability of translated Urdu scale was significantly high (α = .86).

Beck Depression Inventory-21 (BDI-21): This scale consists of 21-items and each item is measured on a response format that ranged from 0–3 point score. A composite score is calculated by adding all items, which could range between 0-63 points. Beck suggested depression could ranges from normal (1-10) to mild (11- 16) to borderline (17-20) to moderate (21- 30) to severe (31-63) levels (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). This inventory had significant reliability (α = .91) for the current sample. Three Items Loneliness Scale: This is comprised of three questions, like how often do you feel socially excluded? etc. The response format ranged from 1 (hardly ever) to 3 (often) (Hughes, Waite, Hawkley, & Cacioppo, 2004). The Urdu version had significantly high reliability (α = .81) in the current study. Procedure

The study was supervised by an ophthalmologist who assisted in patient selection for the study research. Demographic information was collected first followed by asking patients to complete the three instruments that measured their ability to perform daily tasks dependent of vision, depression, and loneliness. Since most patients were partially blind and unable to read the scales, researcher read items from each scale and asked patients to rate each item. Participants did not report any problem in understanding the questions or responding to them. At the end of each session participants were thanked and data was analyzed with SPSS (V 23.0).

Results

Table 1 displayed self-reported five daily life tasks carried out by DME patients dependent on visual abilities. Average measures of DA suggested 266 (93%) patients had a lot of difficulty performing these tasks that required them to see at a distance; 2 (2%) patients could not do these tasks at all. A smaller group 19 (21%) of patients could do these tasks with a little difficulty or no difficulty at all. Similarly, average measures of NA revealed 277 (95.25%)

Table 1 Descriptive Statistics of Tasks Dependent on Vision Vision Dependent Tasks 1Rating Score [N(%)] Distance Acuity 4 3 2 1 Distinguishing a person’s features across room 6(6.89) 11(12.64) 265(92.65) 4(4.59) Distinguishing a person’s features across the street

5(5.74) 9(10.34) 268(93.71) 4(4.59)

Watching TV 1(1.14) 7(8.04) 278(97.20) 0(0.00) Recognizing seasonal changes 12(13.79) 25(28.73) 249(87.06) 0(0.00) Enjoying the scenery if outside for drive 7(8.04) 14(16.09) 265(92.65) 0(0.00) Reading road signs/street names 3(3.44) 9(10.34) 272(95.10) 2(2.29) Average *6(6.51) 13(14.37) 266(93.00) 2(1.92) Near Acuity Noticing objects to either side 7(8.04) 9(10.34) 270(94.41) 0(0.00) Seeing steps and using them 0(0.00) 4(4.59) 279(97.55) 3(3.44) To cut food 5(5.74) 7(8.04) 269(94.05) 5(5.74) To pour drink in glass 4(4.59) 10(11.49) 270(94.41) 2(2.29) To cut nails 0(0.00) 0(0.00) 281(98.25) 5(5.74) Using kitchen appliances 6(6.89) 8(9.19) 268(93.71) 4(4.59) Distinguishing a person’s features at arm’s length

5(5.74) 10(11.49) 270(94.41) 1(1.14)

Average *4(4.43) 7(7.88) 272(95.25) 3(3.28) Light-Dark Adaptation To adjust in light after being in the dark 6(6.89) 17(19.54) 263(91.95) 0(0.00) To adjust in dark after being in the light 5(5.74) 17(19.54) 264(92.31) 0(0.00) Average *6(6.32) 17(19.54) 263(92.13) 0(0.00) Reading Comprehension Reading normal sized newspaper 4(4.59) 11(12.64) 267(77.01) 4(4.59) Reading newspaper headlines 10(11.49) 17(19.54) 258(67.81) 1(1.14) Reading correspondence, e.g., bills, letters, cards 0(.00) 4(4.59) 278(90.80) 4(4.59) Signing documents (cheques, pension book) 0(.00) 9(10.34) 272(83.90) 5(5.74) Identifying money from purse or wallet 6(6.89) 7(8.04) 268(79.31) 5(5.74) Average *4(4.61) 10(11.06) 268(79.76) 4(4.38) Vision Dependent Motor Task 2Rating Score [N(%)] Walking Around 4 3 2 1 In your immediate neighborhood 5(5.74) 12(13.79) 269(94.05) 0(0.00) Outside your immediate neighborhood 5(5.74) 8(9.19) 271(94.75) 2(2.29) Average *5(5.75) 10(11.49) 270(94.40) 1(1.15) Note. 1Rating Score: 4 (no difficulty at all), 3 (a little difficulty), 2 (A lot of difficulty) to 1 (cannot see to do)2Rating Score: 4 (Extremely), 3 (Somewhat), 2 (Barely), 1 (Not at all) *Patient numbers are rounded to the nearest decimal.

patients had a lot of difficulty performing tasks that required them to see at close range; in fact, 3 (3%) patients could not do these tasks at all. A small minority 13 (15%) of patients could do these tasks with a little difficulty or no difficulty at all. For LDA, 263 (92.13%) patients had a lot of difficulty performing tasks that required them to adapt to light and dark conditions. A group of 22 (26%) of patients could do these tasks with a little difficulty or no difficulty at all. Two sixty-

eight (79.76%) patients had great deal of difficulty in comprehending what they read, 4 (4%) patients. could not comprehend what they read. Fourteen (16%) patients could read and comprehend material with little or no difficulty. Finally, 270 (94.40%) patients could barely perform short and long walking tasks, and one (1%) patient could not perform these tasks at all, where 15 (16%) patients could walk short and long distances with little or no difficulty.

Table 2 Correlation among Vision Dependent Tasks, Depression, and Loneliness Vision Dependent Tasks Depression Loneliness Variable DA NA LDA RC WA ND MD BD MDD SD ML MDL SL DA - .76† .66† .53† .32† .04 -.12* -23† -.43† -.49† -.16† -.29† -.56† NA - .46† .70† .62† .00 -.19† -.21† -.45† -.51† .06 -.42† -.62† LDA - .54† .65† -.11* -.13† -.16† -.39† -.41† .03 -.56† -.60† RC - .94† -.10* -26† -.32† -.49† -.72† .05 -.36† -.69† WA - -.09* -.20† -.23† -.58† -.84† -.11* -.42† -.79† ND - -.09* -.13† .07 .00 .04 .00 .04 MD - -.35† -.23† -.24† -.08* .01 .02 BD - .30† .25† -.13† -.19† -.09* MDD - .56† -.14† -.46† -.43† SD - -.11* -.47† -.64† ML - -.25† -.11† MDL - -.45† SL - Note. DA = Distance Acuity; NA = Near Acuity; LDA = Light-Dark Adaptation; RC = Reading Comprehension; WA = Walking Around; ND = Normal Depression; MD = Mild Depression; BD = Borderline Depression; MDD = Moderate Depression; SD = Severe Depression; ML= Mild Loneliness; MDL = Moderate Loneliness; SL = Severe Loneliness *p<.05, †p<.01

Table 2 illustrated DA positively and significantly (p < .01) related to other visually dependent tasks, like NA (r = .76), LDA (r = .66), RC (r = .53), and WA (r = .32), which suggested as far away acuity became poor, close distance acuity, adaptation to light and darkness, understanding reading material and walking short and long distances also became poor. Outcomes further elaborated that decreased distance and near vision dependence were increasing the depression levels and loneliness among patients. Results showed more interesting findings by displaying that patient with walking dependence were severely depressed, r = -.84, p < .01 and severely lonely, r = -.79, p < .01. After that the correlation values were high for reading dependence with severe depression, r= -.72, p < .01 and loneliness, r = -.69, p <.01. It was seen that dependence on near vision was significantly negatively associated with moderate, r = -.45, p <.01 and severe depression, r = -.51, p < .01 and also with moderate, r = -.42, p <.01 and severe loneliness, r = -.62, p < .01. The inverse associations of DDV, DNV, LDA, DW, and DR were also seen with mild, borderline depression and mild level of loneliness but correlation values were substantially high for moderate and severe depression and loneliness. Distance vision dependence also significantly negatively related to severe depression, r = -.49, p < .01 and severe loneliness, r = -.56, p <.01. Consequently, patients suffering from depression were feeling lonelier. Table 3 ANOVA for Depression and Loneliness across Different Cohorts Measures Early adulthood

M(SD) Middle Adulthood

M(SD) Late Adulthood

M(SD) F p

Depression 45.43(11.09) 25.78(9.81) 26.41(9.00) 56.21 .00* Loneliness 7.81(.04) 4.55(.01) 5.01(.10) 22.01 .00* Note.*p<.05

Outcomes revealed that participants in early adulthood were more depressed, F (1, 285) = 56.21, p < .05 and lonelier F (1, 285) = 7.81, p<.05 than those in middle and late adulthood while no differences were seen among participants in middle and late adulthood. The averages of depression for participants in early adulthood reached to clinical levels (severe depression;30-63) and also experiencing severe social loneliness.

Conclusion

DME is a troublesome complication of diabetes mellitus. Since this disease damages the retina, loss of vision is an inevitable consequence that can progressively worsen over time. DME patients are more likely to experience restrictions in independence, mobility, cognitive deficits, and social isolation especially individuals in early adulthood are the most affected as it is the actual time to enjoy the springs of life but the adversity of illness was affecting their mental and social health at a greater extent.

Implications

The current study suggests health professionals and care takers that they should focus on the psychological and social health of patient (along medical treatment) to keep them relaxed and stress free to combat well with their illness.

Limitations

Patients in different cohorts were studied but other important factors like gender differences etc. were not studied. Also, qualitative study to gain an in-depth information about patients’ biopsychosocial health and experimental studies to develop better understanding of the studied constructs were not carried out.

References

Basit, A., Fawwad, A., Qureshi, H., NDSP Members, et al. (2018). Prevalence of diabetes, pre-diabetes and associated risk factors: second National Diabetes Survey of Pakistan (NDSP), 2016–2017. BMJ Open, 8: e020961. doi:10.1136/bmjopen-2017-020961

Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4(6):561-71. doi.10.1001/archpsyc.

1961.01710120031004. Hughes, M.E., Waite, L.J., Hawkley, L.C., & Cacioppo, J.T. (2004). A short scale for measuring

loneliness in large surveys: Results from two population-based studies. Research on Aging,

26(6):655-672. doi: 10.1177/0164027504268574 Schmier, J., Halpern, M., & Covert, D. (2006). Validation of the daily living tasks dependent on

vision (DLTV) questionnaire in a US population with age-related macular degeneration. Ophthalmic Epidemiology, 13(2):137-43. doi:10.1080/09286580600573049.