Letter to the Editor: Beyond retinal lesions: Social support provides critical protection from psychological distress in patients with diabetic retinopathy

Abstract

Diabetic retinopathy (DR) is a leading cause of visual impairment and is associated with psychological distress. Yuan et al recently published a study in the World Journal of Psychiatry, which examined risk factors associated with anxiety and depression in these patients. The risk was greater for patients with non-proliferative DR, longer duration of diabetes, greater visual disturbance, hypertension, and family history of diabetes; the risk was less for those who received more social support (Social Support Rating Scale ≥ 35). This underscores the need to integrate psychological screening and assessment of social support into the care of these patients. This letter highlights the novelties of this new study, emphasizes the need for targeted interventions that improve social support for these patients, and calls for further large-scale studies to validate these findings for patients with proliferative DR. Use of a holistic approach to address retinal pathology and psychological well-being may significantly improve the quality of life and clinical outcomes of patients with DR.

Key Words: Diabetic retinopathy; Social support; Psychological distress; Biopsychosocial model; Diabetic retinopathy screening

Core Tip: Diabetic retinopathy (DR) is closely linked to psychological distress, with social support acting as a key protective factor. This study proposes targeted strategies—including standardized assessments, stratified support systems, and enhanced perceived support—to integrate psychosocial care into DR management, highlighting the value of a biopsychosocial model for improving patient outcomes.

TO THE EDITOR

We read with great interest the in-press study by Yuan et al[1] entitled “Psychological states in diabetic retinopathy: Social support correlates and risk factors” in the World Journal of Psychiatry. The authors are to be commended for conducting a well-designed observational study that provides compelling evidence of the high burden of psychological distress in patients with diabetic retinopathy (DR) and the robust inverse association of psychological distress with social support. Their findings that 49.60% of DR patients suffer from anxiety or depression, and that social support protected against psychological distress — particularly in patients with non-proliferative DR — fill a critical gap in current research. They identified the key risk factors for psychological distress as having diabetes mellitus (DM) for 8 years or more years, greater visual disturbance, hypertension, and family history of DM. These are valuable insights for clinical practitioners and underscore the urgent need to consider psychosocial factors when managing patients with DR. Similar considerations are important for patients with other eye diseases, such as glaucoma[2].

There is a bidirectional link between DR and psychological distress: Emotional distress can lead to poor glycemic control and treatment compliance and accelerate retinal damage; DR-related visual impairment can exacerbate emotional distress. The study of Yuan et al[1] clarifies this complex interaction because it demonstrated that social support [assessed using the Social Support Rating Scale (SSRS)], had inverse correlations with scores for anxiety (r = -0.418, P < 0.001) and depression (r = -0.388, P < 0.001). Thus, social support is a modifiable factor that can potentially affect mental health and disease outcomes in patients with DR. These important insights should be used to develop structured social support interventions for the routine care of these patients. We suggest several key strategies based on the clinical evidence presented in this study.

Clinical integration of social support interventions

Studies of DM have consistently shown that social support is significantly associated with diabetes self-management (DSM) and quality of life[3]. Yuan et al[1] identified specific high-risk groups (e.g., those with long duration of DM and greater visual impairment), indicating these groups should receive targeted interventions. We therefore suggest establishment and integration of standardized social support assessment systems using validated tools, such as the SSRS employed in this study, when caring for patients with DR. In high-volume ophthalmology clinics, trained nursing staff or medical assistants can be easily trained to administer SSRS assessments during routine pre-consultation because this task does not require specialized ophthalmic expertise. This will not impose an unnecessary burden on ophthalmologists (who lack psychiatric training), keep costs under control, and is adaptable to diverse clinical settings. Given that research on integrating the assessment of social support and psychological interventions in the care of patients with DR is not yet established, we believe it is premature to define a universal SRSS threshold for referral. Instead, we propose that future collaborations between psychiatric and ophthalmic specialists should develop evidence-based standards that rigorously ensure clinical applicability and develop SRSS thresholds. For high-risk patients, assessment of social support should accompany ophthalmic follow-ups to help identify unmet psychosocial needs[4,5]. Previous research indicated that short-term social support interventions improved the control of glycated hemoglobin[6], suggesting that integrating supportive care with metabolic management may benefit patients with DR. This aligns with the findings of Yuan et al[1] that greater social support (SSRS ≥ 35) was a protective factor in clinical settings. Unfortunately, there are currently no protocols for identifying SSRS thresholds, so further studies are needed before specific protocols can be implemented.

Construction of a stratified support system

Because the needs of DR patients are affected by disease stage and socioeconomic factors, a stratified support system seems essential. This system should provide basic remote support that has broad accessibility; intermediate support consisting of multidisciplinary care for patients with proliferative DR (PDR); and advanced support, such as community programs, for underserved regions. This system can be modified according to local healthcare resources and economic conditions.

Basic support: Basic support should consist of a remote support system, such as phone case management, to provide education about DR, reminders of medical appointments, and emotional counseling[7]. This basic support relies on existing healthcare infrastructure (e.g., hospital call centers and community health-service hotlines) and can be adapted to different settings. Trained nursing staff or community health workers can conduct follow-ups as part of their routine duties. Although this will slightly increase their workload, this can be considered an acceptable trade-off for addressing the psychosocial needs of these patients. This approach increases access to healthcare for patients with limited mobility due to visual impairment. Although there are no specific data on the remote management of patients with DR, a randomized trial in China that examined patients with coronary heart disease demonstrated that the remote management of patients (which included telephone follow-ups) significantly reduced the rate of major adverse cardiovascular and cerebrovascular events at 1 year (3.5% vs 5.3%, P = 0.04) and also led to improved control of blood pressure. This provides robust evidence for the feasibility of the proposed basic remote support[8].

Intermediate support: Yuan et al[1] reported a non-significant negative correlation between social support and psychological distress in patients with PDR, although they only examined a small number of these patients. Nonetheless, previous studies demonstrated that these patients may benefit from a multidisciplinary and collaborative network of professionals in ophthalmology, endocrinology, and psychology[9,10]. These interventions should be implemented through joint clinical or teleconsultation platforms that utilize in-house personnel and existing hospital resources with only minor additions. Previous studies highlighted the importance of psychological interventions for patients receiving anti-vascular endothelial growth factor (anti-VEGF) therapy[9] to address the psychological stress associated with PDR and these ocular injections. Nurse care coordinators, who are responsible for coordinating patient care among departments, can facilitate referrals between ophthalmic and psychological services and ensure regular follow-up. This support can improve patient adherence to anti-VEGF therapy and decrease treatment-related anxiety and logistical barriers.

Advanced support: Advanced community-based social support programs should be used for resource-limited areas, such as rural regions. These programs can use existing primary care networks, such as community health centers, and general practitioners or family physicians can integrate DR-related counseling and support into routine home and outpatient consultations. This approach does not require separate training workshops and the use of existing healthcare workers helps to control costs. A study of rural Chinese patients with type 2 DM demonstrated that provision of social support improved DSM[3], a specific challenge in this population. This community-based intervention can be established in an existing primary care system, so that it is sustainable in regions with different resources.

Strategies to enhance perceived support

Recent research characterized DR as a “ceramideopathy”, suggesting that psychological stress may exacerbate pathological processes[11]. The study of Yuan et al[1] demonstrated that social support, particularly subjectively perceived social support, can decrease psychological distress. However, the mechanism responsible for this effect is not yet known. Therefore, we can only make general suggestions for future research and clinical practice: (1) Implement peer-support programs in which DR patients who recovered some vision share coping experiences to establish a sense of community and reduce feelings of isolation; (2) Provide family empowerment training so that relatives can help care for DR patients using skills and communication strategies that are commonly used for informal support; and (3) Increase access to mental health resources by developing digital support platforms that use artificial intelligence to deliver personalized psychological support[12].

Linking screening promotion with social support

Global data indicated that 75% of the burden of DR is in regions with inadequate healthcare resources[13]. To address this disparity, social support should be integrated into national DR screening programs, such as those reported in Thailand[14]. Community health workers can play a pivotal role in facilitating the entire process, from screening and referral to follow-up[15]. Interventions that address the social determinants of health, such as income inequality and healthcare access, can increase the impact of screening[16]. This holistic approach aligns with the findings of Yuan et al[1] that higher household income may decrease the risk of psychological distress (P = 0.059).

Critical discussion on mechanisms and methodological considerations

Yuan et al[1] identified an inverse correlation between the amount of social support and the level of psychological distress in patients with DR. However, they did not identify the underlying mechanisms and the study had some methodological limitations. Crucially, they did not examine stress-buffering, self-efficacy, and improved DSM as factors that may have mediated the connection between social support and psychological well-being. Our suggested interventions address these issues, in that peer support and family training can decrease stress, programs led by community health workers can increase self-efficacy, and collaborative teams of healthcare workers can improve DSM. Furthermore, Yuan et al[1] relied on a self-reported metric (which can introduce several types of bias) and their cross-sectional design does not allow causal inferences. Additionally, they only examined a small number of patients with PDR. These limitations highlight the need for future large-scale prospective studies to identify the mechanisms of the associations described by Yuan et al[1], and the need for the collection of more objective data to decrease the several types of bias inherent to self-administered questionnaires.

Long-term effectiveness evaluation mechanisms

Given the limitations of the Yuan et al’s study[1], especially the relatively small sample size and lack of long-term follow-up, we suggest that large-scale, prospective, and long-term studies are needed to verify the dose-response relationship between social support and progression of PDR[9,10], examine cultural differences in the effectiveness of different types of social support[3], and investigate the association between social support and objective biological markers, such as corneal nerve measurements[17].

In conclusion, the study of Yuan et al[1] is a significant contribution to our understanding of the psychological burden of DR and the effect of social support on this relationship. Their findings point to the need to change from a purely biomedical approach to a biopsychosocial approach for management of DR that integrates medical care and social support. The use of standardized and objective assessment tools, a stratified support system, and screening-support programs may improve the psychological well-being and visual outcomes of patients with DR. Further research is needed to validate and determine the long-term effectiveness of the interventions proposed in this letter so that new clinical guidelines can reduce the burden of DR.

ACKNOWLEDGEMENTS

Thanks to Jing Tang for her help in data collection in this study.