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Indian Journal of Psychological Medicine logoLink to Indian Journal of Psychological Medicine
. 2023 Jun 11;45(6):598–609. doi: 10.1177/02537176231172300

A Multisite Longitudinal Investigation of Psychological Outcomes Following Cataract Surgery in India

S G Prem Kumar 1, Pankaj Vishwakarma 1, Dhanaji Ranpise 1, Shobhana Chavan 1, Radhika Krishnan 2, Elizabeth Kurian 1, Team MFV Mental Health Study
PMCID: PMC10964873  PMID: 38545519

Abstract

Background:

Systematic data on mental health issues among adults with cataracts are not available from India. This study explored the impact of cataract surgery on depressive and generalized anxiety (GA) symptoms in an adult Indian sample.

Methods:

A multicenter, prospective, longitudinal cohort study was conducted. Subjects were recruited from four tertiary eye hospitals to assess depression, GA, and associated risk factors. A follow-up survey was carried out at 6 (n = 273, group 1), 12 (n = 198, group 2), or 18 months (n = 105, group 3) post-cataract surgery. Variations in the intensity of depression and GA were assessed using multiple classification analysis (MCA).

Results:

A total of 576 patients completed both baseline and follow-up assessments. The mean (SD) depression score was 25.6 (8.5) before surgery and 8.6 (7.7), 9.9 (7), and 9.8 (6.8), respectively, post-surgery for the three groups on the Center for Epidemiologic Studies Depression scale (CES-D). The mean GA score was 6.7 (4.2) at baseline and 1.1 (2.3), 1 (1.8), and 0.6 (1.3) after surgery on the Generalized Anxiety Disorder scale (GAD-7). MCA showed that factors with the highest impact on the mean change scores for both depressive and GA symptoms were restoration of vision post-surgery (β = 0.381 and 0.185) in group 1, regaining functional independence and female sex in group 2 (β = 0.192 and 0.23), and the presence of ocular comorbidities in the fellow eye (β = 0.36 and 0.315) in group 3.

Conclusion:

Mental health symptoms improved significantly post-cataract surgery across the three groups. The urgent need to invest in strategies that enable early cataract case detection and treat ocular anomalies in the fellow eye is highlighted.

Keywords: Cataract surgery, depression, anxiety, mental health, CES-D scale, GAD-7 scale, India

Key Messages:

  • As compared to the general population in India, patients with untreated cataracts were 9-fold and 2-fold more likely to suffer from depressive symptoms and generalized anxiety symptoms, respectively.

  • Successful cataract surgery resulted in a significant drop in both depressive and generalized anxiety symptoms.

  • Restoration of vision post-surgery had the highest impact on both depressive and generalized anxiety symptoms at 6 months, while regaining functional independence post-surgery and ocular comorbidities in the fellow eye had the highest impact at 12 and 18 months, respectively.

Estimates as recent as 2017 indicate that there were about 197.3 million people with mental disorders in India, including 45.7 million with depressive disorders and 44.9 million with anxiety disorders, with a prevalence of 3.3% each in the general population for depressive and anxiety disorders. 1 A recent study revealed a prevalence of depressive disorder among the institutionalized elderly persons in a southern Indian city with visual impairment (VI) at 20.9%. 2 The baseline findings from this study indicated that adults with untreated cataracts had a prevalence of 87.4% and 57.1% for depressive and anxiety disorders, respectively, with a comorbid depressive and anxiety disorder prevalence of 56.6%. 3 Mental health issues, such as depression, are known to be associated with VI in the older adults.3,4 WHO too estimates that people with VI are three times more likely to suffer from depression and anxiety disorders. 5

While most estimates are based on cross-sectional studies that looked at the association of untreated cataracts with psychiatric symptoms, very few studies have reported longitudinal data on the changes in psychiatric symptoms post-treatment. Studies that evaluated depression before and after cataract surgery thus far have revealed that cataract surgery positively affected depressive symptoms in adults.6–23 No longitudinal studies have looked at the impact of cataract surgery on psychological attributes among Indian adults. With one in seven Indians affected by mental disorders of varying severity and cataracts being the leading cause of reversible blindness in India, corrective cataract surgery may be an effective strategy for decreasing the burden of mental health disorders among those with VI in the country.1,3,24 To understand this dynamic, a longitudinal study was conducted among Indian populations identified with cataracts to determine the impact of vision loss due to cataracts on mental health before and after surgery. This study focuses on postoperative changes in depressive and GA symptoms and their determinants as a consequence of successful cataract surgery.

Material and Methods

A multisite, longitudinal, closed-cohort survey was conducted at four tertiary, not-for-profit eye hospitals spread across four northern and western Indian states. Institutional ethics approval for this study was obtained. The detailed sampling, methodology, and data collection procedures for the baseline study have been reported previously. 3 The methods relevant to this article are as follows.

Study Participants

The study population comprised adults presenting to the ophthalmology department of four tertiary eye hospitals. They were either walk-in patients or referrals from outreach eye-screening camps. Individuals aged 18 years or older who presented for the first eye surgery with no obvious cognitive or auditory deficits and could understand at least one of the four languages, namely, Gujarati, Marathi, Hindi, or English, were considered eligible for participation.

Sample Size

A random-proportional sampling technique was adopted to sample all eligible participants. The sample was proportionately distributed among the four hospitals based on the number of cataract surgeries performed in the preceding financial year. The sample size was estimated based on two previous longitudinal studies that looked at the impact of cataract surgery on depression symptoms, where the mean depressive symptom scores decreased from 8.03 before surgery to 7.02 at follow-up.14,19 With two-sided statistical significance of 5% and 90% power, 632 patients would be required. This was increased to 820 to account for a 30% loss in follow-up in a longitudinal study. Detailed sample size calculations were reported previously. 3

Data Collection: Follow-up Survey

The data collection procedures followed during the baseline have been reported previously. 3 Data for the follow-up survey were collected from December 2018 to January 2020. The postoperative sample was divided into three equal groups to assess the long-term impact of cataract surgery on mental health. The participants in each group were distinct, independent random samples from the total study sample, each of which was followed up at three different time points. Group 1 was followed up at 6 months post-successful cataract surgery, group 2 at 12 months, and group 3 at 18 months. With complications of cataract surgery accounting for more than 7% of avoidable blindness burden in India, 24 the postoperative sample was divided into three distinct groups to understand the immediate to mid-term effects of successful cataract surgery on mental health outcomes and to document if the psychological gains made immediately following cataract surgery were sustained over time. Data collection for the follow-up survey took place at the participant’s residence. Standard research protocols were followed during data collection in accordance with the Helsinki Declaration. Prior intimation was done, and the appointment from the participant was taken for an interview telephonically. After contacting the participant and briefly explaining the study, written informed consent for participation was sought. If the person agreed to participate, the interviewer then administered the follow-up study instrument on a one-to-one basis with no person other than the participant and interviewer present. The interview took around 45 min, and the responses were recorded on paper copies. All interviews were conducted by trained interviewers who were observed regularly by supervisors. The same interviewers conducted both baseline and follow-up interviews. If a person refused to participate, a follow-up refusal form was used to record the reasons for refusal. If we could not contact a person even after three attempts, the reasons for the same were recorded in the follow-up listing sheet.

Visual Acuity Measurement

Before the start of the face-to-face interviews, the visual acuity (VA) details were recorded by the interviewers, who are well-trained in assessing the VA using a Snellen tumbling E chart. The respondent was made to stand/sit at a particular well-lit place, and the interviewer would stand holding the E chart, facing the patients at a distance of 6 m. The 6-m distance was measured using a precisely measured rope. Starting from the top, the participant was asked to point in the exact direction of the hands (up, down, left, and right) of the letter “E” on the chart. Based on the number of lines the respondent reads on the chart, the VA of the patient was determined.

Measures

The interview documented the sociodemographic characteristics of the subjects, including age, sex, education, occupation, place of residence, and current living arrangements. Details on pre-operative VA, spectacle usage, type of cataract, comorbid ocular conditions in the fellow eye, eye selected for cataract surgery, and other general health conditions were extracted from the individual patient medical records available with the treating hospitals.

Depression

The 20-point Center for Epidemiologic Studies Depression scale (CES-D) was used, which determines the 1-week prevalence of subthreshold depression.25,26 It has been previously used to assess depressive symptoms in ophthalmic patients with cataracts, including among Indian adult populations.3,19,20,27–31 The scale was translated into the local languages by the researchers and then back-translated and field-tested to ensure proper readability. The researchers closely collaborated with mental health experts and the participating hospital staff to achieve accuracy in cultural understanding and translation.

Generalized Anxiety Disorder

We used the 7-point Generalized Anxiety Disorder scale (GAD-7) designed to assess generalized anxiety disorder symptoms in adults.32–36 The GAD-7 scale was also appropriately translated into local languages, then back-translated and field-tested to ensure proper readability.

Neglect and Mistreatment

A history of neglect or mistreatment by friends, family, or relatives due to poor vision was documented. Neglect was defined as the denial of basic needs such as food and/or shelter. Mistreatment was defined as subjecting patients to verbal abuse, threats of violence, physical beatings, or mental abuse. ‘Neglect’ and ‘mistreatment’ were assessed separately. The current difficulty in performing daily tasks and requiring help was also documented.

Visual Acuity

Measures of VI were classified into four broad categories as defined by the International Statistical Classification of Diseases and Related Health Problems (ICD-10): very good (equal to or better than 6/12), good (cannot see 6/12 but can see 6/18), moderate (worse than 6/18 to 6/60), and poor (worse than 6/60).24,37

Statistical Analysis

Microsoft Office Excel 2013 and SPSS statistical software (version 20.0, IBM SPSS Science, Chicago, IL) were used to analyze the data. Descriptive statistics for depression and generalized anxiety (GA) scores are reported for relevant variables, and the Chi-square test and one-way ANOVA test were used to assess significance as appropriate. 38 The distribution and association of depression and GA scores with select sociodemographic, clinical, and behavioral attributes are presented separately for the three groups. We report the prevalence of depression score of >20 and GA score of >10.32–36,39 Multiple classification analysis (MCA) was performed separately for the three groups to assess the relationship between the change in the intensity of depression and GA symptoms with select factors. Mean change scores were computed as the difference between the pre- and postoperative scores. We used this change score for depression and GA as a continuous variable in MCA, as clinical cut-off scores for these conditions are not available for adults in India. 95% confidence intervals (CI) are reported as appropriate.

Results

Participation and Demography – Baseline

The findings from the baseline assessment of this study were reported previously. 3 A summary of baseline patient sociodemography is presented. A total of 820 adults were approached, of whom 813 (99.1%) participated. Of these, over half were male (56.1%). The median ages were 62 and 60 for men and women. About two-thirds were currently married (66.8%). Most participants had no formal education (57.4%), and about one-third were currently not working (36.2%). A total of 401 had moderate VI, followed by those with severe VI (19.2%), and around 11.5% (n = 84) were blind. The overall prevalence of depression score of >20 was 71.7% (95% CI 68.5%–74.8%), and a GA score of >10 was 57.1% (95% CI 53.5%–60.7%). The prevalence of comorbid depressive and anxiety symptoms was 50.2% (95% CI 46.7%–53.7%).

Participation and Demography – Follow-up

Out of the baseline cohort of 813 patients, 576 (70.8%) completed the follow-up survey. The response rate was 100% (n = 273), 73.1% (n = 198), and 38.7% (n = 105) for groups 1, 2, and 3, respectively. A total of 65 (24%) and 166 (61.3%) participants could not be contacted in groups 2 and 3, for reasons such as “migration” (group 2: 56%; group 3: 38%), “inaccessible location” (group 2: 14%; group 3: 6%), and “deceased” (group 2: 12%; group 3: 18%, Figure 1). Results are presented only for participants who completed both baseline and follow-up assessments.

Figure 1. Participation Details of the Patients in the Follow-up Survey.

Figure 1.

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Table 1 describes the sociodemographic profile of the participants in the follow-up survey. The median age of participants for the three groups was 62, 62, and 60 years, respectively. The proportion of male participants was higher across all three groups (59%, 62.6%, and 60%, respectively). The majority were uneducated across three groups (53.8%, 62.6%, and 62.9%). Overall, 389 (67.5%) were currently married, and approximately 35% (n = 202) were currently not working or unemployed.

Table 1.

Distribution of Depression25, 26 Scores by Select Sociodemographic, Clinical, and Behavioral Risk Characteristics Before and After Cataract Surgery.

Variable Categories Pre-Operative Depression Score Postoperative Depression Score
Group 1 Group 2 Group 3
Total (%) n = 576 Mean (SD) P Total (%) n = 273 Mean (SD) P Total (%) n = 198 Mean (SD) P Total (%) n = 105 Mean (SD) P
Age ≤50 years 33 (5.7%) 22.9 (8.6) 0.108 16 (5.9%) 9.5 (6.9) 0.554 7 (3.5%) 9.1 (4.2) 0.822 10 (9.5%) 14.5 (8.8) 0.002
51–69 years 434 (75.3%) 25.8 (8.4) 208 (76.2%) 8.3 (7.5) 152 (76.8%) 10 (7.3) 74 (70.5%) 8.3 (6.4)
≥70 years 109 (18.9%) 25.8 (9.1) 49 (17.9%) 9.5 (8.5) 39 (19.7%) 9.3 (6.3) 21 (20%) 12.6 (5.6)
Sex Male 348 (60.4%) 24.4 (8.5) <0.001 161 (59%) 7.7 (7.3) 0.027 124 (62.6%) 9.5 (7.2) 0.343 63 (60%) 9.4 (6.5) 0.472
Female 228 (39.6%) 27.5 (8.2) 112 (41%) 9.8 (8.1) 74 (37.4%) 10.5 (6.5) 42 (40%) 10.4 (7.3)
Marital status Never married 11 (1.9%) 26.6 (10.2) 0.265 5 (1.8%) 13.2 (4.9) 0.248 2 (1%) 12.5 (14.8) 0.784 4 (3.8%) 13.5 (7) 0.404
Currently married 389 (67.5%) 25.2 (8.6) 175 (64.1%) 8.2 (7.5) 143 (72.2%) 9.7 (6.7) 71 (67.6%) 10 (6.8)
Previously married 176 (30.6%) 26.4 (8.3) 93 (34.1%) 9.1 (8) 53 (26.8%) 10.2 (7.7) 30 (28.6%) 8.8 (6.8)
Education Illiterate 337 (58.5%) 26.5 (8.3) 0.002 147 (53.8%) 10.7 (7.9) <0.001 124 (62.6%) 10.4 (6.9) 0.161 66 (62.9%) 10.2 (6.5) 0.413
Literate 239 (41.5%) 24.3 (8.7) 126 (46.2%) 6.2 (6.7) 74 (37.4%) 8.9 (7.1) 39 (37.1%) 9.1 (7.4)
Current occupation Not working 202 (35.1%) 26 (8.8) 0.157 90 (33%) 11.1 (8.2) 0.001 81 (40.9%) 10.2 (6.1) 0.163 31 (29.5%) 10.8 (5.6) 0.248
Self-employed 184 (31.9%) 24.6 (9.1) 91 (33.3%) 7.6 (6.9) 63 (31.8%) 10.9 (8.4) 30 (28.6%) 10.7 (6.9)
Work for income 190 (33%) 26.2 (7.6) 92 (33.7%) 7 (7.4) 54 (27.3%) 8 (6) 44 (41.9%) 8.5 (7.4)
Living arrangements Staying with family 527 (91.5%) 25.3 (8.6) 0.014 255 (93.4%) 8.7 (7.7) 0.28 181 (91.4%) 9.9 (6.8) 0.117 91 (86.7%) 9.9 (6.7) 0.527
Staying alone 34 (5.9%) 29.7 (7.9) 13 (4.8%) 7.7 (7.4) 14 (7.1) 8.1 (8.6) 7 (6.7%) 11 (7)
Staying with relatives/friends 15 (2.6%) 26.9 (5.5) 5 (1.8%) 3.4 (5) 3 (1.5%) 17.3 (4.6) 7 (6.7%) 7.1 (8.2)
VA in the operated eye† Very good 16 (3%) 25.5 (8.2) 0.001 208 (76.2%) 8.4 (7.6) 0.007 125 (63.1%) 8.8 (6.4) 0.005 66 (62.9%) 9.9 (7.1) 0.582
Good 27 (5.1%) 27.4 (7.6) 42 (15.4%) 8.9 (7.9) 36 (18.2%) 10.5 (7.2) 22 (21%) 10 (6.8)
Borderline 287 (54.5%) 25.8 (7.3) 10 (3.7%) 7.1 (6) 25 (12.6%) 11 (7.1) 3 (2.9%) 4.3 (5.1)
Poor 197 (37.4%) 27.6 (8.4) 13 (4.8%) 11.1 (9.6) 12 (6.1%) 15.8 (9.2) 14 (13.3%) 10.1 (5.9)
Type of cataract Nuclear cataract 468 (85.7%) 25.7 (8.5) 0.762 219 (82.6%) 8 (7.6) 0.047 157 (86.7%) 9.8 (7.4) 0.553 92 (92%) 9.3 (6.8) 0.279
Cataracts other than nuclear 78 (14.3%) 25.4 (9.4) 46 (17.4%) 10.4 (7.9) 24 (13.3%) 8.9 (4.6) 8 (8%) 12 (4.4)
Ocular morbidities in the fellow eye Yes 332 (57.6%) 26 (7.9) 0.008 172 (63%) 6 (6.6) <0.001 105 (53%) 8.3 (6.6) 0.001 55 (52.4%) 7.7 (8) 0.001
No 244 (42.4%) 25.1 (9.4) 101 (37%) 13 (7.3) 93 (47%) 11.6 (7) 50 (47.6%) 12.1 (4.2)
Suffer other health conditions Yes 198 (34.4%) 25.8 (8.9) 0.754 108 (39.6%) 9.9 (7.7) 0.002 67 (33.8%) 11.2 (6) 0.052 23 (21.9%) 7.3 (5.7) 0.048
No 378 (65.6%) 25.5 (8.4) 165 (60.4%) 7.7 (7.5) 131 (66.2%) 9.2 (7.4) 82 (78.1%) 10.5 (7)
Suffer from poor vision before surgery ≤1 year 444 (77.1%) 25.6 (8.5) 0.865 211 (77.3%) 8.2 (7.9) 0.107 150 (75.8%) 9.4 (6.7) 0.16 83 (79%) 98.7 (6.8) 0.845
>1 year 132 (22.9%) 25.3 (8.8) 62 (22.7%) 10 (6.7) 48 (24.2%) 11.1 (7.9) 22 (21%) 10.1 (7.4)
Facing difficulties and requiring help with daily tasks Facing difficulty and requiring help 294 (51%) 28.3 (7.4) <0.001 10 (3.7%) 20.3 (8.3) <0.001 7 (3.5%) 24.7 (10.8) <0.001 3 (2.9%) 13.7 (0.6) 0.002
Facing difficulty but do not require help 212 (36.8%) 24.1 (7.9) 13 (4.8%) 15.9 (9.9) 14 (7.1%) 11.4 (5.6) 5 (4.8%) 15 (8.3)
Not facing difficulty but require help 28 (4.9%) 21.7 (8.8) 8 (2.9%) 15.9 (8) 7 (3.5%) 15.3 (7) 12 (11.4%) 15.2 (3)
Neither facing difficulty nor requiring help 42 (7.3%) 16.9 (10.6) 242 (88.6%) 7.5 (6.7) 170 (85.9%) 8.9 (6.1) 85 (81%) 8.6 (6.7)
Neglected and mistreated by family/friends Yes 319 (55.4%) 22.4 (8.3) <0.001 166 (60.8%) 7.6 (7.5) 0.006 88 (44.4%) 9 (7.9) 0.143 61 (58.1%) 9.3 (7.6) 0.433
No 257 (44.6%) 29.6 (7.1) 107 (39.2%) 10.2 (7.7) 110 (55.6%) 10.5 (6.1) 44 (41.9) 10.4 (5.6)
Stay home most of the time due to poor vision Yes 310 (53.8%) 27.1 (8.2) <0.001 35 (12.8%) 10.8 (9.8) 0.068 30 (15.2%) 12.1 (8.9) 0.059 11 (10.5%) 13.8 (5) 0.038
No 266 (46.2%) 23.9 (8.6) 238 (87.2%) 8.3 (7.3) 168 (84.8%) 9.4 (6.5) 94 (89.5%) 9.3 (6.9)
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ANOVA test for significance reported. SD, standard deviation; VA, visual acuity. †49 cases for which data on visual acuity were not available from hospital medical records were excluded from this one-way analysis of variance.

Clinical Characteristics and Visual Acuity

Before cataract surgery, a little over three-quarters (77.1%) had suffered from poor vision for about a year or less; approximately 58% had ocular morbidities in the fellow eye; and about a third suffered from other health conditions. The grades of VA for the operated eye before and after surgery are presented in Table 1. Considerable improvements were noted in the vision at 6, 12, and 18 months post-cataract surgery. Before surgery, a majority (54.5%) had a moderate VA, followed by those with a poor VA (37.4%) in the eye selected for surgery. However, after the surgery, approximately 76%, 63%, and 63% had very good VA in the three groups.

Functional Activity Limitation Due to Vision

Before the surgery, over half (51%) of all participants reported facing difficulty and requiring help with daily activities because of poor vision. However, this changed significantly post-surgery, with over 85% of respondents across the three groups reporting neither facing difficulty nor requiring help with their daily activities. Similarly, before surgery, a little over half (53.8%) reported that they stayed indoors for the majority of the time due to their poor vision, which too changed significantly post-surgery, with 85% reporting not being confined to home for each of the three groups (Table 1).

Neglect and Mistreatment Faced Due to Vision

Before the surgery, over half (55.4%) of all participants reported being neglected or mistreated by friends or family. However, this did not change significantly post-surgery, with approximately 55% of respondents across the three groups reporting being neglected or mistreated by friends or family (Table 1).

Score Distribution

Depression

Table 1 shows the distribution of mean scores for depression and its association with select variables before and after the surgery. The overall mean depression score was 25.6 (SD 8.5) before surgery and 8.6 (SD 7.7; 66.4% drop), 9.9 (SD 7; 61.3% drop), and 9.8 (SD 6.8; 61.7% drop) post-surgery, for the three groups. The overall prevalence of depression (CES-D) score of ≥20 was 77.8% (95% CI 74.2%–81.1%) in the baseline and 9.2% (95% CI 6.0%–13.2%), 9.6% (95% CI 5.9%–14.6%), and 8.6% (95% CI 4.0%–15.7%) post-surgery. Before the surgery, significantly higher levels of mean depression score were observed among women (mean: 27.5 ± 8.2, p < 0.001), those who were uneducated (26.5±8.3, p = 0.002), those staying alone (29.7 + 7.9, p = 0.014), and those with poor VA (27.6 + 8.4, p = 0.001). However, this changed post-surgery. Among group 1, at 6-month follow-up, significantly lower depression scores were seen in women than men (p = 0.027), those with poor VA (11.1 + 9.6, p = 0.007), those who reported neither facing any difficulty nor requiring help to perform their daily activities (7.5 + 6.7, p < 0.001), and those who reported not being neglected or mistreated because of their poor vision (10.2 + 7.7, p = 0.006). Among group 2, a significant drop in depression scores was observed among those with very good VA (8.8 + 6.4, p = 0.005) and those who reported neither facing any difficulty nor requiring help to perform their daily activities (8.9 + 6.1, p < 0.001). Among group 3, a significant drop in depressive symptoms was observed among those who reported neither facing any difficulty nor requiring help to perform their daily activities (8.6 + 6.7, p = 0.002), those who no longer need to stay home most of the time (9.3 + 6.9, p = 0.05) and those without any ocular morbidities in the fellow eye (12.1 + 4.2, p = 0.001, Table 1). Improvements in post-surgery depressive symptoms were seen in 89.7%, 90.4%, and 88.6% of patients in the three groups (data not shown).

Generalized Anxiety

Table 2 shows the distribution of mean scores for GA with select variables for the adults, pre- and post-cataract surgery. The overall mean GA score was 6.7 + 4.2 before surgery and 1.1 + 2.3 (83.6% drop), 1 + 1.8 (85.1% drop), and 0.6 + 1.3 (91% drop) post-surgery for the three groups. The overall prevalence of GA (GAD-7 score of ≥10) was 59.9% (95% CI 55.8%–63.9%) at baseline and 5.5% (95% CI 3.1%–8.9%), 3.5% (95% CI 1.4%–7.2%), and 1.9% (95% CI 0.2%–6.7%) post-surgery. Before surgery, significantly higher mean GA scores were observed among women (7.4 + 4.2, p = 0.001), those staying alone (8.7 + 4.4, p = 0.015), those with poor uncorrected VA (7.4 + 4.3, p = 0.008), those facing difficulty and requiring help with daily activities (7.8 + 4.1, p < 0.001), and those staying home most of the time due to poor vision (7.6 + 4.3, p < 0.001). Post-surgery, in group 1, significantly lower GA symptoms scores were seen in those with very good VA than those with moderate or poor VA (p = 0.003), those who reported neither facing any difficulty nor requiring help to perform their daily activities (0.7 + 1.8, p < 0.001), and those who reported no longer being neglected or mistreated because of their poor vision (1.1 + 2.4, p = 0.003). Among group 2, a significant drop in GA scores was observed among those currently living with their families (0.9 + 1.7, p = 0.032) and those who reported neither facing any difficulty nor requiring help to perform their daily activities (0.7 + 1.1, p < 0.001). Among group 3, a significant drop in GA symptoms was observed among those who no longer needed to stay home most of the time (0.9 + 1.5, p = 0.003) (Table 2). Post-surgery, GA symptoms were improved in 84.6%, 89.4%, and 83.8% of patients in the three groups (data not shown).

Table 2.

Distribution of Generalized Anxiety32-36 Scores by Select Sociodemographic, Clinical, and Behavioral Risk Characteristics Before and After Cataract Surgery.

Variable Categories Pre-Operative GA Score Postoperative GA Score
Group 1 Group 2 Group 3
Total (%) n = 576 Mean (SD) P Total (%) n = 273 Mean (SD) P Total (%) n = 198 Mean (SD) P Total (%) n = 105 Mean (SD) P
Age ≤50 years 33 (5.7%) 5.2 (2.9) 0.096 16 (5.9%) 0.8 (1) 0.202 7 (3.5%) 1.1 (0.9) 0.945 10 (9.5%) 0.3 (0.5) 0.701
51–69 years 434 (75.3%) 6.8 (4.1) 208 (76.2%) 1 (2.3) 152 (76.8%) 0.9 (1.9) 74 (70.5%) 0.6 (1.4)
≥70 years 109 (18.9%) 6.8 (4.7) 49 (17.9%) 1.6 (2.6) 39 (19.7%) 1 (1.4) 21 (20%) 0.7 (1.1)
Sex Male 348 (60.4%) 6.2 (4.2) 0.001 161 (59%) 1 (2.3) 0.361 124 (62.6%) 0.9 (1.8) 0.803 63 (60%) 0.6 (1.3) 0.64
Female 228 (39.6%) 7.4 (4.2) 112 (41%) 1.2 (2.4) 74 (37.4%) 1 (1.7) 42 (40%) 0.5 (1.2)
Marital status Never married 11 (1.9%) 5.8 (3) 0.763 5 (1.8%) 0.4 (0.5) 0.697 2 (1%) 1 (1.4) 0.65 4 (3.8%) 0 (0) 0.334
Currently married 389 (67.5%) 6.7 (4.3) 175 (64.1%) 1 (2.4) 143 (72.2%) 0.9 (1.7) 71 (67.6%) 0.7 (1.4)
Previously married 176 (30.6%) 6.7 (3.9) 93 (34.1%) 1.2 (2.3) 53 (26.8%) 1.2 (1.8) 30 (28.6%) 0.4 (0.8)
Education Illiterate 337 (58.5%) 7 (4.1) 0.038 147 (53.8%) 1.4 (2.7) 0.009 124 (62.6%) 0.9 (1.6) 0.803 66 (62.9%) 0.6 (1.1) 0.91
Literate 239 (41.5%) 6.3 (4.2) 126 (46.2%) 0.7 (1.7) 74 (37.4%) 1 (2.1) 39 (37.1%) 0.6 (1.5)
Current occupation Not working 202 (35.1%) 7.1 (4.5) 0.217 90 (33%) 1.2 (2.7) 0.81 81 (40.9%) 1.2 (1.9) 0.051 31 (29.5%) 0.4 (0.8) 0.722
Self-employed 184 (31.9%) 6.3 (4) 91 (33.3%) 0.9 (2) 63 (31.8%) 1 (2) 30 (28.6%) 0.7 (1.6)
Work for income 190 (33%) 6.6 (3.9) 92 (33.7%) 1.1 (2.4) 54 (27.3%) 0.5 (0.9) 44 (41.9%) 0.6 (1.3)
Living arrangements Staying with family 527 (91.5%) 6.6 (4.2) 0.015 255 (93.4%) 1.1 (2.4) 0.769 181 (91.4%) 0.9 (1.7) 0.032 91 (86.7%) 0.6 (1.3) 0.47
Staying alone 34 (5.9%) 8.7 (4.4) 13 (4.8%) 0.9 (1.9) 14 (7.1) 1.4 (1.9) 7 (6.7%) 0.6 (1.1)
Staying with relatives/friends 15 (2.6%) 6.6 (2.2) 5 (1.8%) 0.4 (0.9) 3 (1.5%) 3.3 (4.9) 7 (6.7%) 0 (0)
VA in the operated eye† Very good 16 (3%) 6.7 (4.1) 0.008 208 (76.2%) 1.1 (2.3) 0.003 125 (63.1%) 0.8 (1.5) 0.104 66 (62.9%) 0.6 (1.5) 0.82
Good 27 (5.1%) 7.7 (4.7) 42 (15.4%) 0.8 (1.6) 36 (18.2%) 1.2 (2.2) 22 (21%) 0.5 (0.8)
Borderline 287 (54.5%) 6.6 (3.8) 10 (3.7%) 0.4 (0.8) 25 (12.6%) 1.2 (1.5) 3 (2.9%) 0 (0)
Poor 197 (37.4%) 7.4 (4.3) 13 (4.8%) 2.3 (4.6) 12 (6.1%) 1.9 (2.6) 14 (13.3%) 0.6 (0.9)
Type of cataract Nuclear cataract 468 (85.7%) 6.6 (4) 0.574 219 (82.6%) 0.9 (2.1) 0.003 157 (86.7%) 1 (1.4) 0.149 92 (92%) 0.4 (1) 0.028
Cataracts other than nuclear 78 (14.3%) 6.3 (4.4) 46 (17.4%) 2 (3.1) 24 (13.3%) 0.9 (1.8) 8 (8%) 1.3 (1.6)
Ocular morbidities in the fellow eye Yes 332 (57.6%) 6.9 (4.1) 0.177 172 (63%) 0.8 (1.8) 0.036 105 (53%) 0.9 (1.5) 0.531 55 (52.4%) 0.6 (1.6) 0.827
No 244 (42.4%) 6.4 (4.3) 101 (37%) 1.5 (3.1) 93 (47%) 1 (2) 50 (47.6%) 0.6 (0.8)
Suffer from other health conditions Yes 198 (34.4%) 7.2 (4.4) 0.044 108 (39.6%) 1.1 (2.2) 0.686 67 (33.8%) 1 (1.4) 0.952 23 (21.9%) 0.7 (1.7) 0.598
No 378 (65.6%) 6.5 (4) 165 (60.4%) 1 (2.4) 131 (66.2%) 1 (1.9) 82 (78.1%) 0.5 (1.1)
Suffer from poor vision before surgery ≤1 year 444 (77.1%) 6.7 (4.1) 0.68 211 (77.3%) 0.9 (2.1) 0.034 150 (75.8%) 1 (1.8) 0.995 83 (79%) 0.6 (1.4) 0.391
>1 year 132 (22.9%) 6.6 (4.2) 62 (22.7%) 1.6 (2.9) 48 (24.2%) 1 (1.5) 22 (21%) 0.4 (0.7)
Facing difficulties and requiring help with daily tasks Facing difficulty and requiring help 294 (51%) 7.8 (4.1) <0.001 10 (3.7%) 5.2 (5.3) <0.001 7 (3.5%) 5.9 (3.5) <0.001 3 (2.9%) 1.3 (2.3) 0.385
Facing difficulty but do not require help 212 (36.8%) 6 (3.9) 13 (4.8%) 4.2 (3.6) 14 (7.1%) 2.1 (3) 5 (4.8%) 0 (0)
Not facing difficulty but require help 28 (4.9%) 4.5 (3.8) 8 (2.9%) 1 (1.5) 7 (3.5%) 0.9 (1.1) 12 (11.4%) 0.9 (0.8)
Neither facing difficulty nor requiring help 42 (7.3%) 3.8 (3.8) 242 (88.6%) 0.7 (1.8) 170 (85.9%) 0.7 (1.1) 85 (81%) 0.5 (1.3)
Neglected and mistreated by family/friends Yes 319 (55.4%) 5.6 (3.9) <0.001 166 (60.8%) 1 (2.3) 0.003 88 (44.4%) 1.2 (2.1) 0.153 61 (58.1%) 0.6 (1.5) 0.982
No 257 (44.6%) 8 (4.1) 107 (39.2%) 1.1 (2.4) 110 (55.6%) 0.8 (1.4) 44 (41.9) 0.6 (0.9)
Stay home most of the time due to poor vision Yes 310 (53.8%) 7.6 (4.3) <0.001 35 (12.8%) 1.6 (2.8) 0.144 30 (15.2%) 1.6 (2.7) 0.03 11 (10.5%) 1.6 (2) 0.003
No 266 (46.2%) 5.7 (3.8) 238 (87.2%) 1 (2.3) 168 (84.8%) 0.9 (1.5) 94 (89.5%) 0.5 (1.1)
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ANOVA test for significance reported. GA, generalized anxiety; SD, standard deviation; VA, visual acuity. †49 cases for which data on visual acuity were not available from hospital medical records were excluded from this one-way analysis of variance

Depression-Anxiety Comorbidity

The baseline prevalence of comorbid depression-anxiety symptoms was 54.9% (95% CI 50.7%–59.0%). Post-surgery, the comorbid depression-anxiety symptoms diminished significantly over time, with a prevalence of 2.6% (95% CI 1.0%–5.2%) in group 1, 3.0% (95% CI 1.1%–6.5%) in group 2, and 1.9% (95% CI 0.2%–6.7%) in group 3.

Determinants of Changes in Depression and Generalized Anxiety Levels Post-Surgery

Table 3 shows the MCA for the adjusted predicted mean change scores for depression. As expected, among group 1 participants, the highest effect on the intensity of depression was seen in those with borderline and poor VA and those suffering from ocular morbidities in the fellow eye, with a beta value of 0.381 (p = 0.003) and 0.256 (p < 0.001), respectively. In group 2, those neither facing any difficulties nor requiring help with daily activities and women had the highest effect on the intensity of depression, with a beta value of 0.192 (p = 0.042) and 0.190 (p = 0.023), respectively. Among group 3, those suffering from ocular morbidities in the fellow eye and those over 50 years had the highest effect, with a beta value of 0.360 (p = 0.001) and 0.277 (p = 0.012), respectively.

Table 3.

MCA for Effect of Selected Variables on Depression Post-Cataract Surgery.

Variable Categories Mean Change Score (Adjusted Predicted Mean for Depression)†
Group 1 Group 2 Group 3
n = 273 Mean β P n = 198 Mean β P n = 105 Mean β P
Age ≤50 years 16 14.6 0.053 0.657 7 9.1 0.133 0.174 10 6.1 0.277 0.012
51–69 years 208 17.0 152 17.1 74 16.1
≥70 years 49 17.5 39 16.1 21 12.8
Sex Male 161 16.0 0.103 0.126 124 15.0 0.19 0.023 63 14.0 0.058 0.592
Female 112 18.4 74 19.4 42 15.3
Education Illiterate 147 15.9 0.095 0.143 124 16.5 0.01 0.895 66 14.9 0.053 0.601
Literate 126 18.1 74 16.8 39 13.7
Occupation Currently not working 90 15.3 0.148 0.049 81 17.0 0.064 0.697 31 16.3 0.236 0.053
Self-employed/Small business 91 16.2 63 15.6 30 10.4
Salaried/Work for income 92 19.3 54 17.2 44 16.0
BCVA in the operated eye Very good 208 16.9 0.381 0.003 125 16.8 0.1 0.62 66 13.9 0.138 0.55
Good 42 18.3 36 17.7 22 14.1
Borderline 10 19.1 25 16.0 3 22.0
Poor 13 19.7 12 12.6 14 16.2
Ocular morbidities in the fellow eye Yes 172 19.2 0.256 <0.001 105 17.1 0.044 0.543 55 18.2 0.36 0.001
No 101 13.1 93 16.1 50 10.4
Suffer from other health conditions Yes 108 15.6 0.095 0.11 67 16.0 0.04 0.575 23 14.9 0.022 0.82
No 165 17.8 131 16.9 82 14.4
facing difficulties and requiring help with daily tasks Facing difficulty and requiring help 10 7.2 0.212 0.005 7 11.7 0.192 0.042 3 17.7 0.193 0.241
Facing difficulty but do not require help 13 10.6 14 14.5 5 10.4
Not facing difficulty but require help 8 14.9 7 7.4 12 9.6
Neither facing difficulty nor requiring help 242 17.8 170 17.4 85 15.3
Neglected and mistreated by family/friends Yes 166 17.9 0.106 0.07 88 17.2 0.048 0.511 61 15.4 0.103 0.282
No 107 15.4 110 16.1 44 13.2
Stay home most of the time due to poor vision Yes 35 15.5 0.046 0.426 30 11.8 0.182 0.013 11 12.2 0.072 0.48
No 238 17.2 168 17.5 94 14.8
  Full model 273   0.450 <0.001 198   0.394 <0.001 105   0.583 <0.001
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BCVA, best corrected visual acuity; MCA, multiple classification analysis. †The mean change score is calculated as the difference from pre- to post-surgery scores.

Table 4 shows the MCA for the adjusted predicted mean change scores for GA scores. Among group 1 participants, those with improved VA and those requiring help with daily activities had the highest effect on the intensity of GA, with a beta value of 0.185 (p = 0.005) and 0.171 (p = 0.033), respectively. In group 2, women and those aged more than 50 had the highest effect on the intensity of GA, with a beta value of 0.230 (p = 0.006) and 0.225 (p = 0.007), respectively. In group 3, those suffering from ocular morbidities in the fellow eye and those currently not working had the highest effect, with a beta value of 0.315 (p = 0.004) and 0.281 (p = 0.044), respectively.

Table 4.

MCA for Effect of Selected Variables on Generalized Anxiety Post-Cataract Surgery.

Variable Categories Mean Change Score (Adjusted Predicted Mean for Generalized Anxiety)†
Group 1 Group 2 Group 3
n = 273 Mean β P n = 198 Mean β P n = 105 Mean β P
Age ≤50 years 16 4.4 0.061 0.606 7 1.2 0.225 0.007 10 4.8 0.032 0.949
51–69 years 208 5.7 152 6.9 74 4.6
≥70 years 49 5.5 39 6.4 21 4.8
Sex Male 161 5.3 0.057 0.423 124 5.8 0.23 0.006 63 4.1 0.203 0.083
Female 112 5.9 74 8.0 42 5.6
Education Illiterate 147 5.3 0.051 0.454 124 7.1 0.123 0.11 66 4.7 0.016 0.883
Literate 126 5.8 74 5.9 39 4.6
Occupation Currently not working 90 5.3 0.047 0.773 81 6.8 0.028 0.927 31 6.2 0.281 0.044
Self-employed/Small business 91 5.5 63 6.5 30 3.8
Salaried/Work for income 92 5.8 54 6.5 44 4.2
BCVA in the operated eye Very good 208 5.3 0.185 0.005 125 6.5 0.161 0.206 66 4.6 0.184 0.326
Good 42 7.4 36 6.6 22 4.0
Borderline 10 4.8 25 5.9 3 7.5
Poor 13 5.0 12 9.5 14 5.5
Ocular morbidities in the fellow eye Yes 172 6.0 0.111 0.087 105 6.3 0.077 0.286 55 5.7 0.315 0.004
No 101 4.9 93 7.0 50 3.5
Suffer from other health conditions Yes 108 5.4 0.032 0.617 67 7.1 0.079 0.259 23 5.0 0.049 0.633
No 165 5.7 131 6.3 82 4.6
Facing difficulties and requiring help with daily tasks Facing difficulty and requiring help 10 2.4 0.171 0.033 7 3.0 0.188 0.043 3 5.4 0.112 0.72
Facing difficulty but do not require help 13 3.4 14 6.5 5 6.3
Not facing difficulty but require help 8 7.6 7 3.9 12 4.2
Neither facing difficulty nor requiring help 242 5.7 170 6.9 85 4.6
Neglected and mistreated by family/friends Yes 166 5.9 0.079 0.207 88 7.2 0.104 0.154 61 4.9 0.088 0.386
No 107 5.1 110 6.2 44 4.3
Stay home most of the time due to poor vision Yes 35 5.4 0.016 0.797 30 5.5 0.101 0.162 11 5.1 0.043 0.693
No 238 5.6 168 6.8 94 4.6
  Full model 273   0.096 <0.001 198   0.167 <0.001 105   0.251 <0.001
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BCVA, best corrected visual acuity; MCA, multiple classification analysis. †The mean change score is calculated as the difference from pre- to post-surgery scores.

Discussion

This is one of the first long-term longitudinal studies to examine the impact of cataract surgery on depressive and GA symptoms in an adult Indian sample. While there was only one study, to the best of the authors’ knowledge, that reported longitudinal data on the impact of cataract surgery on GA, 15 however, there were a handful of studies that reported data on depressive symptoms previously, whose findings were comparable to that of ours.6–9,11,14,15,18–23 Compared to the general population in India, patients with untreated cataracts examined in this study were 9-fold as likely to suffer from depressive symptoms and 2-fold from GA. 1 As expected, the mean scores for depression and GA witnessed a significant drop post-surgery across all three groups. Restoration of vision post-surgery had the highest impact on both depressive and GA symptoms in the short-run (at 6 months), while regaining functional independence post-surgery seems to contribute to improved mental health symptoms at 12 months. In the long run (at 18 months), however, the highest impact on the mean change scores for both depression and GA was seen in patients diagnosed with ocular comorbidities in the fellow eye.

The very high rates of both depressive and GA symptoms among ophthalmic patients before cataract surgery are a major public health concern that needs attention. While most patients examined suffered from poor vision for about a year or less, about a quarter of them reportedly suffered beyond 1 year. Enabling early cataract-case detection and offering appropriate treatment not only restores vision but is also vital in addressing their unmet psychological needs. Evidence suggests that delay in presentation to the hospital for cataract surgery is a major challenge that is largely unaddressed, specifically in rural communities. 40 Several studies have reported on the barriers to the uptake of cataract surgical services from the perspective of patients and suggested ways to enhance access.41–45 Evidence also indicates that waiting time for cataract surgery adversely influences patient choices and attitudes.46,47 Therefore, it is, imperative that policymakers, program planners, and implementing eye hospitals formulate appropriate measures and interventions that enable early case detection and prompt treatment of cataracts. Efforts to boost community eye screening while utilizing the services of trained community health workers (CHWs) would be an effective strategy for early case detection. 48 Another effective strategy to further improve cataract surgical coverage (CSC) is establishing standalone satellite eye clinics called Vision Centers (VC) that are strategically located to maximize reach and improve access to primary eye care. Evidence suggests that this strategy is also both cost-efficient and sustainable over the long run.49,50 As evident from the findings, restoration of vision significantly improved both depressive and GA symptoms in the short run. Thus, efforts to further improve early cataract case detection and its subsequent surgical treatments are the way forward.

Apart from high levels of specific mental health problems such as depression and GA, over half (55%) of subjects exhibited comorbid depression and GA symptoms before surgery, which is worrisome. Although depression and anxiety have historically been seen as distinct conditions, the two disorders are not mutually exclusive. They often coexist to varying degrees in the same individual,51,52 and patients with comorbid depression and anxiety frequently also have a poorer prognosis and a lower response to treatment.51,52 This finding has strong intervention implications for mental health outcomes among cataract patients. Investing in and stepping up patient counseling services and incorporating counseling into regular ophthalmic service delivery mechanisms, both at the treating hospital and as part of community outreach activities such as eye screening camps, where the bulk of cataract detection happens, would help nullify mental health comorbidities to some extent and encourage patients to opt for cataract surgery at the earliest.

Gaining functional independence in performing daily tasks without needing help from others, specifically for those who aged 50 years and older, was associated with a greater reduction in both depressive and GA symptoms post-surgery in the intermediate group assessed at 12 months. Regaining functional independence was previously reported to be strongly associated with significant improvements in the quality of life, including better psychological outcomes.53,54 With about two-thirds of the sample engaged in some form of active work, it is understandable that vision restoration post-surgery is associated with reduced psychological distress. This suggests that increased engagement in work may lead to increased self-efficacy and satisfaction, which, in turn, improve psychological well-being.

In the long run, however, patients with ocular morbidities in the fellow eye reported significant reductions in both depressive and GA symptoms. A study conducted among the Vietnamese adult population revealed that first but not second eye cataract surgery has a small benefit for depressive symptoms. 19 Additionally, a UK-based randomized control trial of older women who underwent second eye surgery found no difference in depressive symptoms. 55 About 58% of patients examined in this study were diagnosed with various ocular ailments in the fellow eye, ranging from cataracts to glaucoma, strabismus to age-related macular degeneration, and pterygium, among others. These anomalies in the fellow eye seem to have remained unaddressed even until 18 months following the first-eye cataract surgery, though we have not ascertained the reasons for this. It is evident that being able to see well in the operated eye has positively impacted mental health outcomes in the long run. Compared to group 1 participants, who reported a 66.4% drop in depressive symptoms, the patients in group 3 registered a modest 61.7% drop. This relatively modest drop in psychological outcomes could be attributed to untreated ocular ailments in the fellow eye. Efforts to screen and treat these ocular ailments in the fellow eye at the earliest could further reduce psychological distress in these patients and enhance their overall well-being and quality of life.

The present findings must be considered in light of the study’s limitations. While the three distinct follow-up cohorts stem from the same baseline cohort, which was done to understand if the psychological gains made immediately following cataract surgery were sustained over time, we acknowledge that a repeated assessment of the same cohort over three different time periods would have allowed us to examine for trends and avoid the influence of confounding factors across the three groups, which was not done in the current assessment. Additionally, the three groups assessed in the follow-up sample were not controlled for confounding factors like age, gender, and so on, which might influence psychological outcomes; hence, the findings should be interpreted cautiously. We recorded certain baseline clinical parameters, like VA readings, from the medical records available at the treating hospital; however, such data were unavailable for some of the participants, and they were excluded from the analysis. Additionally, data on the history of psychological distress were not available in the patient’s medical records, which did not allow us to examine the effects of these parameters on the current mental health status. We relied on self-reported psychological distress during the interview and did not clinically confirm the psychiatric diagnoses. For this reason, conclusions from this study should be confined to the construct of psychological distress and not extended to specific psychological diagnoses. Although this study attempted to examine patients post-surgery at three different time intervals, the study’s results should be interpreted with caution due to the low response rates, particularly in group 3 patients. The clinical cut-offs for depression or GA scores are not readily available for adults in India. Hence, the reported prevalence rates need to be interpreted with caution. Finally, using the same interviewers in both the baseline and follow-up assessments could have introduced an element of bias.

Conclusion

This study provides evidence supporting a higher prevalence of mental health symptoms among adult patients awaiting cataract surgery and shows that, most often, their mental health needs remain unaddressed. Cataract surgery is an important intervention that improves visual functioning and significantly alleviates psychological distress. Strategies that guarantee early case detection and subsequent treatment, like utilizing the services of trained CHWs and investing in establishing more VC to improve access, are urgently needed. The need to treat cataracts and other ocular anomalies in the fellow eye is highlighted.

Acknowledgments

The authors would like to thank the participants of this study and the staff of the partner hospitals for facilitating their recruitment. The MFV Mental Health Study Team contributed to the planning of the study logistics and data collection, and the members of this team other than the named authors include (in alphabetical order): Gautam Kumar Narwal, Jahirkhan Pathan, Komal Rupekar, Nitesh Kumar Shukla, Pravin Gend, Sandeep Ahire, and Vibhuji Patel.

Footnotes

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

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