Association Between Depression and Severity of Dry Eye Symptoms, Signs, and Inflammatory Markers in the DREAM Study

Yi Zhou, James Murrough, Yinxi Yu, Neeta Roy, Rony Sayegh, Penny Asbell, Maureen G. Maguire, Gui Shuang Ying

Research output: Contribution to journalArticlepeer-review

10 Scopus citations


Importance: Depression is more prevalent in patients with dry eye disease (DED) than in the general population; however, the association between severity of DED and depression needs further evaluation. Objective: To investigate the association between depression and severity of DED symptoms and signs, including inflammatory markers. Design, Setting, and Participants: Secondary cross-sectional and longitudinal analysis performed in April to December 2020 of data from Dry Eye Assessment and Management (DREAM) study, a randomized clinical trial from October 2014 to July 2016 including patients with moderate to severe symptoms and signs of DED. Enrolled from 27 ophthalmology and optometry centers, both academic and private, in 17 US states, 535 patients were followed up for 1 year. Exposure: Participants screened positive for depression if they scored 42 or less on the Mental Component Summary (MCS) of the 36-Item Short Form Health Survey. Main Outcomes and Measures: Symptoms of DED were assessed by Ocular Surface Disease Index (OSDI) and Brief Ocular Discomfort Index (BODI) and signs assessed by tear film breakup time, Schirmer test, corneal and conjunctival staining, tear osmolarity, and meibomian gland dysfunction at baseline, 6 months, and 12 months. A composite severity sign score was calculated from all 6 signs. Inflammatory markers (cytokines in tears and HLA-DR expression by conjunctival surface cells) were measured for some trial participants. Features of DED were compared between participants with and without depression and adjusted for age, sex, race, visits, and baseline comorbidities. Results: Among the 535 participants, mean (SD) age was 58 (13.2) years, 434 participants (81%) were women, and 398 (74.4%) were White. Participants who screened positive for depression had worse DED symptoms by OSDI (effect size = 0.45, P <.001) and BODI (effect size = 0.46, P <.001) and composite DED sign score (effect size = 0.21, P =.006). Lower MCS score (ie, worse depression) was correlated with higher OSDI score (ie, worse DED symptoms) at baseline (Spearman ρ = -0.09, P =.03), 6 months (ρ = -0.20, P <.001), and 12 months (ρ = -0.21, P <.001). Inflammatory markers did not differ by depression status. Conclusions and Relevance: Depression was associated with more severe dry eye symptoms and overall signs, suggesting that among patients with moderate to severe DED, those with depression may be likely to have more severe DED. These findings support consideration of depression as a comorbidity when managing patients with DED. Further study is needed to elucidate the relationship. 2022 American Medical Association. All rights reserved.

Original languageEnglish
Pages (from-to)392-399
Number of pages8
JournalJAMA Ophthalmology
Issue number4
StatePublished - Apr 2022


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