Psychiatric disorders linked to visual impairment: A review of mental health challenges and interventions across age groups

Abstract

The intersection of visual impairment and mental health has profound effects on quality of life and warrants attention from healthcare providers, educators, and policymakers. With 20 million children under the age of 14 affected globally, older adults also experience significant psychological impact including depression, anxiety, and cognitive impairment. The implications of vision-related challenges extend far beyond mere sight. Depression and anxiety, exacerbated by social isolation and reduced physical activity, underscore the need for comprehensive interventions that address both medical and psychosocial dimensions. By recognizing the profound impact of ocular morbidities like strabismus, myopia, glaucoma, and age-related macular degeneration on mental health and investing in effective treatments and inclusive practices, society can pave the way for a healthier, more equitable future for affected individuals. There is evidence that myopic children experience a higher prevalence of depressive symptoms compared to their normal peers, and interventions like the correction of strabismus can enhance psychological outcome - demonstrating the value of an integrated management approach.

Key Words: Visual impairment; Ocular morbidity; Mental health; Depression; Anxiety; Psychosocial interventions; Quality of life; Cognitive impairment; Older adults; Children

Core Tip: Visual impairment and eye disorders are strongly associated with mental illness, namely depression and anxiety. The interaction is bidirectional: Vision loss can lead to psychological illness, but psychological illness can worsen vision loss through affecting compliance with treatment. Regular screening for psychiatric health in ophthalmic practice and multidisciplinary collaboration are required. Interventions should be tailored to age, severity of visual impairment, and individual psychosocial needs with a focus on coping and functional support.

INTRODUCTION

The World Health Organization has defined visual impairment (VI) as best-corrected visual acuity worse than 3/60 in the better eye. The definition also includes near vision impairment, and that is a near visual acuity worse than N6 despite correction. Nearly 2.2 billion people globally suffer from VI, including 36 million who are blind and 217 million with moderate-to-severe VI[1]. Of the 19 million visually impaired children, 1.4 million have irreversible blindness[2]. The worldwide increase in life expectancy combined with aging has led policymakers to pay particular attention to the visual health of the elderly. VI is particularly prevalent in elderly, and it has been estimated that one in eight older people suffer from some degree of loss of vision. This problem is often compounded by multimorbidity, leading to a cascade of negative health outcomes, including reduced mobility, loss of function, increased dependency, and higher healthcare use[1,3].

Research shows a strong correlation between VI and a number of mental health issues, such as loneliness, social disengagement, anxiety, and depression[2,4-10]. Nevertheless, the psychological effects of vision loss are frequently overlooked[7,10]. VI can affect an individual’s autonomy, interpersonal relationships, and overall quality of life[9,11-14]. This article aims to analyze current literature on the nature of psychiatric disorders in individuals with VI. As opposed to previous reviews that are narrowly grounded in either children or the elderly, the present review synthesizes evidence across age and emphasizes the bidirectionality of the relationship between VI and mental disorders and highlights areas of convergence in treatment.

METHODOLOGY

This review conducted a search across PubMed, MEDLINE, Scopus, EMBASE, Web of Science, and Google Scholar. Inclusion criteria were: (1) Peer-reviewed original research; (2) Participants of any age with diagnosed VI on World Health Organization criteria; and (3) Measurement of at least one mental health outcome (e.g., depression, anxiety, quality of life). Commonly used search terms included “visual impairment”, “blindness”, “low vision”, “emotional problems”, “mental disorders”, “mood disorders”, “depression”, “anxiety”, “psychological distress”, “psychiatric morbidity”, “psychosis”, “sleep disorder”, “myopia”, “glaucoma”, and “strabismus”. We excluded case reports, editorials, and reviews involving participants with major comorbidities since comorbid illnesses (e.g., cardiovascular disease, neurological illness) can in themselves cause psychiatric morbidity, so the particular effect of VI is uncertain.

PSYCHOLOGICAL IMPACT OF VI AND CONTRIBUTING MECHANISMS

VI diminishes autonomy and social interaction, which in turn negatively influence vision-related quality of life. Reduced quality of life in turn increases vulnerability to depression and anxiety and thereby forms a vicious cycle that worsens psychological well-being and further compromise’s functional ability (Figure 1).

Figure 1 Visual impairment and psychiatric disorders - a complex relationship. VI: Visual impairment.

Psychological adaptation, self-concept, and coping

Vision loss necessitates considerable psychological adjustment, which is expected to influence self-concept and identity - particularly in the event of a discrepancy between the “ideal self” and the “current self”[15-18]. Fitzgerald et al[11] discovered that acceptance of blindness at first and pre-illness adjustment were predictors of successful coping and utilization of skill at follow-up. Bauman and Yoder[12] also reported that well-adjusted individuals were emotionally more stable and functionally more successful. Hashemi et al[19], in his population-based cross-sectional study on 3310 people aged 60 and older in Tehran using the General Health Questionnaire, found a persistent correlation between VI and increased rates of depression, anxiety, and suicidal ideation and also elevated scores on standardized measures of psychological distress. It also reported that while the prevalence of depression actually decreases slightly with increasing age after midlife, loss of vision tends to reverse this and so increase the risk of mood disorder. Additionally, older adult anxiety may be tempered by worry at loss of vision over time and associated loss of independence. The study also highlighted that moderately visually impaired people may be more psychologically distressed than the blind, perhaps because of uncertainty and anticipatory grief about failing vision.

Coping skills are at the center of this process of adjustment. Adaptive coping, including intellectualization and acceptance, is linked to fewer depressive symptoms, while maladaptive coping, including denial, projection, or rationalization, may impede emotional recovery[20]. Dodds et al[17] employed structural modelling in their research to highlight constructs of “self as agent” and “internal self-worth”, which are at the center of adjustment and rehabilitation outcomes.

Collectively, these results highlight that adaptation involves not just the functional adjustment to visual loss, but also the preservation of self-esteem and the acquisition of adequate coping skills to safeguard mental health.

Social isolation and interpersonal challenges

VI can make it more difficult to develop critical social skills, which makes it more difficult to build and sustain strong social networks. Also, social settings, not blindness itself, are the cause of mental disorders. Blind people may experience guilt and resentment as a result of sighted people’s assumptions. As a result, social isolation may occur, especially in inclusive educational environments, which may have a negative impact on general well-being[13,14]. Positive family attitudes promote self-concept stabilization, while negative ones intensify maladjustment.

Poor quality of life and functional limitations

In elderly populations, VI is a significant prognosticator of functional deterioration. Studies show that elderly individuals who are vision impaired have a higher likelihood of having an increased risk of difficulty performing basic and instrumental activities of daily living like eating, dressing, medication management, and social interaction. Not only does this deterioration undermine their independence, but it also exacerbates feelings of worthlessness, hopelessness, and loneliness. Augustin et al[21] observed that patients with age-related macular degeneration (AMD) reported poorer self-rated health and higher depressive symptomatology. Additionally, Rovner and Casten[22,23] highlighted those older individuals with VI with comorbid depression had higher rates of physical inactivity, smoking, and obesity. These functional impairments not only restrict mobility and independence but also have a negative impact on daily activities of living, thus increasing the risk of mental health disorders. Hence, it is necessary to reverse functional impairments through low vision rehabilitation and psychological interventions to increase the quality of life in this population.

Sleep disturbance and neurobiological correlates

A diminished visual field and mood are linked to sleep disturbances in conditions such as glaucoma. A study by Noebels et al[24] showed that blind people had reduced resting occipital alpha oscillations when their eyes were closed. In a study by Leger et al[25], all blind individuals had free-running circadian rhythms and shorter sleep duration, lower sleep efficiency, shorter rapid eye movement duration, and longer rapid eye movement latency compared to healthy controls. Miles et al[26] reported that 76% of blind people in their study (n = 50) had sleep-wake disorder and 40% of those people had a cyclical course of symptoms.

Ocular disease and psychiatric comorbidity

The most widely researched is AMD, with 10.5%-44.4% prevalence of depression and up to 32.5% fulfilling major depressive disorder criteria. Severity and bilaterality of visual loss enhance the risk[21-23,27,28]. Glaucoma, particularly pseudoexfoliative and primary angle-closure glaucoma, has greater depression and anxiety symptoms than open-angle glaucoma and controls[29], perhaps due to more rapid progression and a worse prognosis. Strabismus, although generally cosmetic, has associated anxiety and social withdrawal in children. Depressive symptoms are seen in retinitis pigmentosa patients in spite of maintenance of central acuity[30]. Non-infectious ocular inflammatory diseases have roughly 30% depression prevalence despite best visual acuity[31]. Visual hallucinations in Charles Bonnet Syndrome, prevalent in AMD and other diseases, cause distress, anxiety, or paranoia[32,33]. Although these studies identify significant correlations, some of them used cross-sectional designs that did not allow causality to be determined. Moreover, symptomatically, diagnostic depression and anxiety were not identical across each study, and most studies used samples from high-income countries. This restricts generalizability to varying cultural and socioeconomic environments. Future studies should correct these limitations by using standardized diagnostic measures and sampling underrepresented groups.

Bidirectional and associated relationships

There is also a bidirectional, well-documented connection among different ocular diseases and psychiatric diseases such as depression, anxiety, schizophrenia, and bipolar disorder. The knowledge of vision loss is more likely to elicit emotional distress, functional impairment, and social isolation. Psychological distress, in return, may compromise visual health by lowering adherence to treatment routines and increasing physiological stress responses.

While some findings suggest that not all conditions exhibit an immediate causal connection - e.g., Mendelian randomization trials have not been able to set up a clear association between depression, insomnia, schizophrenia, and glaucoma - some studies suggest a built-in psychiatric burden in glaucoma patients. Moreover, pre-existing mental illness, particularly anxiety disorders, can jeopardize the regular use of ocular drugs, thus creating a self-sustaining vicious cycle of worsening disease status and psychological morbidity.

Apart from the mood disorders, cognitive impairment among the elderly has also been linked with vision impairment. Co-occurrence of both sensory and cognitive impairment can have a powerful negative impact on daily functioning and quality of life. Surprisingly, in certain studies, depression has been seen to emerge after vision loss and also hasten cognitive impairment among older individuals with VIs.

MANAGEMENT OF MENTAL HEALTH IN VI

In the elderly, it is critical that overall management plans also consider the interaction between aging, chronic disease, and VI on mental health outcomes. Multidisciplinary care models, including ophthalmology, geriatric psychiatry, occupational therapy, and social services, are of especial significance for the elderly. Early detection of depression and anxiety via organized screening protocols is required, given that these mental illnesses are often undetected in the visually impaired elderly. Effective management of psychological issues requires addressing care of mental health illnesses (like depression and anxiety), enhancement of coping capacity, and functional rehabilitation for VI. Psychosocial treatment interventions that incorporate cognitive-behavioral techniques, problem-solving skills training, and counselling tailored to the individual have been encouraging in improving emotional functioning and lessening distress. Other supportive treatments, including music therapy, instructional programs presented on a group basis, and structured peer support, also may lessen anxiety; more evidence is needed, however, to establish their long-term efficacy[34]. However, the majority of the intervention studies have been small, single-site trials, often without active control groups, which can inflate the impact. Subsequent studies need to be multicentric randomized controlled trials, especially in underrepresented groups, to more rigorously test the effectiveness and feasibility of interventions. Table 1 summarizes age-stratified eye conditions, secondary psychiatric consequences, and proposed multidisciplinary treatments.

Table 1 Psychiatric and psychosocial effects of visual impairment in different age groups with suggested management strategies.

Age group	Common ocular conditions	Psychiatric and psychosocial impact	Suggested management strategies
Children and adolescents	Myopia, strabismus, ROP, congenital blindness	Depression, anxiety, social withdrawal, low self-esteem, peer difficulties, identity issues	Early correction (e.g., myopia glasses, strabismus surgery), parental and school-based support, CBT, REBT, peer interaction training, recreational activity, training in adaptive skills, mobility support, and emotional counselling
Young adults	High myopia, glaucoma, retinitis pigmentosa	Social stigma, fear of disease progression, loss of autonomy, vocational stress, existential anxiety	ACT, problem-solving therapy, vocational rehabilitation, CBT (mood monitoring, cognitive restructuring), counselling, psychosocial education, peer and tele-support, identity re-framing interventions
Middle-aged adults	Diabetic retinopathy, glaucoma, uveitis, cataract	Adjustment disorders, stress, sleep disturbances, relationship strain, anticipatory grief about progressive vision loss	PST, vision rehabilitation, integrated ophthalmology-psychiatry care, emotional support groups, tele-health mental health support, education about prognosis, and promoting lifestyle modification (e.g., smoking cessation, exercise)
Older adults	ARMD, glaucoma, cataract, Charles Bonnet Syndrome	Major depression, cognitive decline, anxiety, loneliness, sleep-wake disturbances, suicidal ideation, increased dependency	Stepped care, CBT/REBT, routine screening with PHQ-9/GAD-7, vision rehabilitation with assistive devices, low vision therapy, group-based interventions, social engagement programs, home safety adaptations, caregiver training, integration of mental health in eye care

ROP: Retinopathy of prematurity; CBT: Cognitive behavioral therapy; REBT: Rational emotive behavior therapy; ACT: Acceptance and commitment therapy; ARMD: Age-related macular degeneration; PST: Problem-solving treatment; PHQ-9: Patient Health Questionnaire 9; GAD-7: Generalized Anxiety Score 7-Item Scale.

Regular screening and early detection

Regular screening for anxiety and depressive disorders can be integrated into ophthalmology clinics via the use of standardized instruments like the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7. High-priority populations for such screening include older adults with AMD, patients with progressive glaucoma, and children with strabismus or amblyopia. In addition, formal referral loops between ophthalmologists, mental health professionals, and vision rehabilitation specialists must be formed in order to facilitate timely intervention[34,35].

Psychological interventions

Self-management interventions: Through these interventions, people learn how to keep an eye on their health and deal with any negative physical or psychological effects. Especially for patients with AMD and severe distress, they can lessen psychological distress and increase self-efficacy[27,28,36,37].

Problem-solving treatment: Problem-solving treatment is a manualized intervention that teaches people how to identify issues, make goals, come up with solutions, and assess results[30]. It is more accessible because non-specialists can deliver it, even over the phone. Problem-solving treatment promotes the continuation of worthwhile activities and may prevent or postpone the onset of depression[38].

Cognitive behavioral therapy: Behavioral activation, cognitive restructuring, and mood monitoring are examples of modified cognitive behavioral therapy interventions that have been successful in reducing anxiety and depression. A form of cognitive therapy called rational emotive behavior therapy has helped blind people feel better about themselves while lowering stress, anxiety, depression, and irrational beliefs[37,39].

Stepped care interventions: This method starts with the least intensive interventions and progresses to more intensive services as necessary. In older adults with subthreshold symptoms, it has been demonstrated to be both successful and economical in preventing anxiety and depression disorders[40]. Stepped care approaches and tailored cognitive behavioral therapy have been successfully implemented among older adults with VI and produced reduced depressive symptoms and enhanced quality of life.

Vision rehabilitation programs

Vision rehabilitation programs combine counselling/support groups, rehabilitation training (e.g., mobility, orientation, and daily living skills), and low vision clinical services (e.g., adaptive devices). They seek to lower the risk of depression, increase self-efficacy, and enhance functioning. One essential element is counselling, particularly with regard to emotional issues[28,36].

Psychosocial interventions

Social support: Social support, particularly from friends, is crucial for lowering symptoms of anxiety, depression, and emotional issues. It is important to teach kids and teens how to make and keep friends. Social support interventions among older adults have also been found to be effective in alleviating loneliness and depressive symptoms that follow vision loss. Interventions provided in community settings, peer support, and programs of organized recreation are able to promote continued social engagement and adaptive coping. Vision rehabilitation services involving counseling and training in adaptive daily living skills are also essential to sustaining independence and psychological well-being.

Independence in mobility: Encouraging mobility independence is essential for improving every child’s mental health. Parents and educators should support children and young adults with VI in becoming as independent as possible.

Recreational activities: Engaging in more recreational and social activities with friends is especially crucial for overall well-being and lowering the risk of mood disorders.

Coping strategies: Youngsters must learn healthy coping mechanisms for disabilities. Acceptance and commitment therapy is one intervention that shows promise for improving psychological adjustment and coping[41]. This can also be helpful to the elderly population through increased psychological flexibility and acceptance of VI.

Systemic and policy-level approaches

Coverage for “cosmetic” treatments, like strabismus surgery, that affect mental health. Free myopia glasses programs to reduce functional disadvantages. Telehealth delivery to improve access. Patient and family education regarding functional and emotional aspects of VI. Integrated care models that integrate ophthalmology, psychiatry, and rehabilitation (Table 1).

CONCLUSION

VI has a strong association with depression, anxiety, and reduced quality of life across the lifespan, and while evidence exists for a reciprocal relationship where psychological health also influences visual outcomes, the mental health needs of individuals with VI are frequently under addressed. Multidisciplinary, patient-focused treatments - such as early psychological screening, cognitive behavior therapy, problem-solving skills, and vision rehabilitation - are crucial to foster resilience and to improve clinical outcomes. Coordination between ophthalmic services, mental health professionals, families, and community systems is imperative. While there are few evidence gaps, most importantly regarding longitudinal effectiveness and culturally responsive practice, integrated models of care provide a promising answer to prevent psychological distress, facilitate independence, and promote well-being for individuals with VI.

ACKNOWLEDGEMENTS

The authors acknowledge the comprehensive prior work in the field of visual impairment and mental health that forms the foundation for this review. We are grateful to the researchers and participants whose studies contribute to our understanding of this critical intersection.