Relationship between Diabetic Retinopathy Disease Severity, Anxiety, and Depression
Main Article Content
Abstract
Purpose: To determine the relationship between nonproliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), anxiety, and depression.
Materials and Methods: This retrospective case-control study identified patients 18 years or older seen by the University of North Carolina Ophthalmology department between July 2008-July 2018 diagnosed with anxiety, depression, NPDR, and PDR. Odds ratios (OR) were calculated separately for the severity of diabetic retinopathy (DR) and anxiety or depression.
Results: Among the 47,740 study subjects, 27,893 (58%) were female, 3,239 (6.8%) had NPDR and 1,430 (3.0%) had PDR. The incidence of anxiety after DR was 1.5%, and the incidence of depression after DR was 2.4%. NPDR (0.997; 0.896-1.110; p<0.001) conveyed no change in odds, while PDR (0.869; 0.756-0.998; p<0.001) demonstrated a reduction in odds for a subsequent diagnosis of anxiety. Compared to other 18-34 year old patients with less severe or no disease, 18-34 year old patients with NPDR (2.801; 1.450-5.408; p=0.003) and PDR (2.999; 1.499-6.001; p=0.004) exhibited an increased odds for subsequent anxiety. NPDR (1.473; 1.342-1.617; p<0.001) and PDR (1.232; 1.092-1.389; p<0.001) demonstrated an increased odds for subsequent diagnosis of depression. When stratifying by age, 18-34 year old patients again had the highest increase in odds for subsequent diagnosis of depression (NPDR 3.452; 1.774-6.719; p<0.001 and PDR 4.382; 2.232-8.603; p<0.001).
Conclusions: Patients with DR have an increased risk for a new diagnosis of depression, and DR severity has a positive linear relationship with the diagnosis of depression. Age likely plays a prominent role in risk stratification for a new diagnosis of anxiety in patients with DR.
Keywords:
diabetic retinopathy, diabetic retinopathy disease severity, anti-VEGF, anxiety, depression
Article Details
How to Cite
LE, Patrick Huan et al.
Relationship between Diabetic Retinopathy Disease Severity, Anxiety, and Depression.
Medical Research Archives, [S.l.], v. 11, n. 8, aug. 2023.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/4120>. Date accessed: 04 dec. 2024.
doi: https://doi.org/10.18103/mra.v11i8.4120.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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3. Khayyat SM, Mohamed MMA, Khayyat SMS, et al. Association between medication adherence and quality of life of patients with diabetes and hypertension attending primary care clinics: a cross-sectional survey. Qual Life Res Int J Qual Life Asp Treat Care Rehabil. 2019;28(4):1053-1061. doi:10.1007/s11136-018-2060-8
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14. Olson D, Zhang X, Ward MF, et al. Rates of Comorbid Anxiety and Depression in Patients With Age-Related Macular Degeneration. J Vitreoretin Dis. 2019;3(4):211-214. doi:10.1177/2474126419849199
15. Zhang X, Olson DJ, Le P, Lin FC, Fleischman D, Davis RM. The Association Between Glaucoma, Anxiety, and Depression in a Large Population. Am J Ophthalmol. 2017;183:37-41. doi:10.1016/j.ajo.2017.07.021
16. van der Vaart R, Weaver MA, Lefebvre C, Davis RM. The Association Between Dry Eye Disease and Depression and Anxiety in a Large Population-Based Study. Am J Ophthalmol. 2015;159(3):470-474. doi:10.1016/j.ajo.2014.11.028
17. Rajput R, Gehlawat P, Gehlan D, Gupta R, Rajput M. Prevalence and predictors of depression and anxiety in patients of diabetes mellitus in a tertiary care center. Indian J Endocrinol Metab. 2016;20(6):746. doi:10.4103/2230-8210.192924
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20. Öztürk ZA, Yeşil Y, Kuyumcu ME, Kepekçi Y. Association of depression and sleep quality with complications of type 2 diabetes in elderly. Eur Geriatr Med. 2013;4:S19. doi:10.1016/j.eurger.2013.07.048
21. Gorska-Ciebiada M, Saryusz-Wolska M, Ciebiada M, Loba J. Mild Cognitive Impairment and Depressive Symptoms in Elderly Patients with Diabetes: Prevalence, Risk Factors, and Comorbidity. J Diabetes Res. 2014;2014:1-7. doi:10.1155/2014/179648
22. Xu X, Zhao X, Qian D, Dong Q, Gu Z. Investigating Factors Associated with Depression of Type 2 Diabetic Retinopathy Patients in China. PloS One. 2015;10(7):e0132616. doi:10.1371/journal.pone.0132616
23. Jafarinezhad A, Zohrevand B, Kalantari S. Association of depression with type 2 diabetes and relevant factors. Adv Biomed Res. 2014;3(1):244. doi:10.4103/2277-9175.145753
24. Le Floch JP, Doucet J, Bauduceau B, Verny C, SFD/SFGG Intergroup. Retinopathy, nephropathy, peripheral neuropathy and geriatric scale scores in elderly people with Type 2 diabetes. Diabet Med. 2014;31(1):107-111. doi:10.1111/dme.12327
25. Mazhar K, Varma R, Choudhury F, et al. Severity of diabetic retinopathy and health-related quality of life: the Los Angeles Latino Eye Study. Ophthalmology. 2011;118(4):649-655. doi:10.1016/j.ophtha.2010.08.003
26. Fenwick EK, Pesudovs K, Khadka J, et al. The impact of diabetic retinopathy on quality of life: qualitative findings from an item bank development project. Qual Life Res Int J Qual Life Asp Treat Care Rehabil. 2012;21(10):1771-1782. doi:10.1007/s11136-012-0110-1
27. Trento M, Passera P, Trevisan M, et al. Quality of life, impaired vision and social role in people with diabetes: a multicenter observational study. Acta Diabetol. 2013;50(6):873-877. doi:10.1007/s00592-013-0470-1
28. Hirai FE, Tielsch JM, Klein BEK, Klein R. Relationship between Retinopathy Severity, Visual Impairment and Depression in Persons with Long-term Type 1 Diabetes. Ophthalmic Epidemiol. 2012;19(4):196-203. doi:10.3109/09286586.2012.692006
29. Granström T, Forsman H, Leksell J, Jani S, Raghib AM, Granstam E. Visual functioning and health-related quality of life in diabetic patients about to undergo anti-vascular endothelial growth factor treatment for sight-threatening macular edema. J Diabetes Complications. 2015;29(8):1183-1190. doi:10.1016/j.jdiacomp.2015.07.026
30. Das T, Wallang B, Semwal P, Basu S, Padhi TR, Ali MH. Changing Clinical Presentation, Current Knowledge-Attitude-Practice, and Current Vision Related Quality of Life in Self-Reported Type 2 Diabetes Patients with Retinopathy in Eastern India: The LVPEI Eye and Diabetes Study. J Ophthalmol. 2016;2016:e3423814. doi:10.1155/2016/3423814
31. Karlson B, Agardh CD. Burden of illness, metabolic control, and complications in relation to depressive symptoms in IDDM patients. Diabet Med J Br Diabet Assoc. 1997;14(12):1066-1072. doi:10.1002/(SICI)1096-9136(199712) 14:12<1066::AID-DIA462>3.0.CO;2-M
32. Lee HJ, Chapa D, Kao CW, et al. Depression, quality of life, and glycemic control in individuals with type 2 diabetes. J Am Acad Nurse Pract. 2009;21(4):214-224. doi:10.1111/j.1745-7599.2009.00396.x
33. Iype T, Shaji SK, Balakrishnan A, Charles D, Varghese AA, Antony TP. Cognition in type 2 diabetes: Association with vascular risk factors, complications of diabetes and depression. Ann Indian Acad Neurol. 2009;12(1):25-27. doi:10.4103/0972-2327.48848
34. Xu X, Zhao X, Qian D, Dong Q, Gu Z. Investigating Factors Associated with Depression of Type 2 Diabetic Retinopathy Patients in China. PloS One. 2015;10(7):e0132616. doi:10.1371/journal.pone.0132616
35. Hirai FE, Tielsch JM, Klein BEK, Klein R. Ten-year change in vision-related quality of life in type 1 diabetes: Wisconsin epidemiologic study of diabetic retinopathy. Ophthalmology. 2011;118(2):353-358. doi:10.1016/j.ophtha.2010.06.022
36. Rees G, Xie J, Fenwick EK, et al. Association Between Diabetes-Related Eye Complications and Symptoms of Anxiety and Depression. JAMA Ophthalmol. 2016;134(9):1007-1014. doi:10.1001/jamaophthalmol.2016.2213
37. Rees G, Xie J, Fenwick EK, et al. Association Between Diabetes-Related Eye Complications and Symptoms of Anxiety and Depression. JAMA Ophthalmol. 2016;134(9):1007-1014. doi:10.1001/jamaophthalmol.2016.2213
38. Fisher L, Skaff MM, Mullan JT, Arean P, Glasgow R, Masharani U. A longitudinal study of affective and anxiety disorders, depressive affect and diabetes distress in adults with Type 2 diabetes. Diabet Med J Br Diabet Assoc. 2008;25 (9):1096-1101. doi:10.1111/j.1464-5491.2008.02533.x
39. Collins MM, Corcoran P, Perry IJ. Anxiety and depression symptoms in patients with diabetes. Diabet Med J Br Diabet Assoc. 2009;26(2):153-161.
doi:10.1111/j.1464-5491.2008.02648.x
40. Henderson AS, Jorm AF, Korten AE, Jacomb P, Christensen H, Rodgers B. Symptoms of depression and anxiety during adult life: evidence for a decline in prevalence with age. Psychol Med. 1998;28(6):1321-1328. doi:10.1017/s0033291798007570
41. Nyman SR, Dibb B, Victor CR, Gosney MA. Emotional well-being and adjustment to vision loss in later life: a meta-synthesis of qualitative studies. Disabil Rehabil. 2012;34(12):971-981. doi:10.3109/09638288.2011.626487
42. Senra H, Balaskas K, Mahmoodi N, Aslam T. Experience of Anti-VEGF Treatment and Clinical Levels of Depression and Anxiety in Patients With Wet Age-Related Macular Degeneration. Am J Ophthalmol. 2017;177:213-224. doi:10.1016/j.ajo.2017.03.005
43. Yu Y, Feng L, Shao Y, et al. Quality of life and emotional change for middle-aged and elderly patients with diabetic retinopathy. Int J Ophthalmol. 2013;6(1):71-74. doi:10.3980/j.issn.2222-3959.2013.01.15
44. Hirai FE, Tielsch JM, Klein BEK, Klein R. Relationship between Retinopathy Severity, Visual Impairment and Depression in Persons with Long-term Type 1 Diabetes. Ophthalmic Epidemiol. 2012;19(4):196-203. doi:10.3109/09286586.2012.692006
45. Radloff LS. The CES-D Scale: A Self-Report Depression Scale for Research in the General Population. Appl Psychol Meas. 1977;1(3):385-401. doi:10.1177/014662167700100306
46. Roberts RE, Kaplan GA, Shema SJ, Strawbridge WJ. Does growing old increase the risk for depression? Am J Psychiatry. 1997;154(10):1384-1390. doi:10.1176/ajp.154.10.1384
47. Borowsky SJ, Rubenstein LV, Meredith LS, Camp P, Jackson-Triche M, Wells KB. Who is at risk of nondetection of mental health problems in primary care? J Gen Intern Med. 2000;15(6):381-388. doi:10.1046/j.1525-1497.2000.12088.x
48. Roy MS, Roy A, Affouf M. Depression is a Risk Factor for Poor Glycemic Control and Retinopathy in African-Americans With Type 1 Diabetes: Psychosom Med. 2007;69(6):537-542. doi:10.1097/PSY.0b013e3180df84e2
49. Yekta Z, Xie D, Bogner HR, et al. The association of antidepressant medications and diabetic retinopathy among people with diabetes. J Diabetes Complications. 2015;29(8):1077-1084. doi:10.1016/j.jdiacomp.2015.06.009
2. Ting DSW, Cheung GCM, Wong TY. Diabetic retinopathy: global prevalence, major risk factors, screening practices and public health challenges: a review. Clin Experiment Ophthalmol. 2016;44(4):260-277. doi:10.1111/ceo.12696
3. Khayyat SM, Mohamed MMA, Khayyat SMS, et al. Association between medication adherence and quality of life of patients with diabetes and hypertension attending primary care clinics: a cross-sectional survey. Qual Life Res Int J Qual Life Asp Treat Care Rehabil. 2019;28(4):1053-1061. doi:10.1007/s11136-018-2060-8
4. Kessler RC. Epidemiology of women and depression. J Affect Disord. 2003;74(1):5-13.
5. Kessler RC, Bromet EJ. The epidemiology of depression across cultures. Annu Rev Public Health. 2013;34:119-138. doi:10.1146/annurev-publhealth-031912-114409
6. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602. doi:10.1001/archpsyc.62.6.593
7. Ali S, Stone M, Skinner T, Robertson N, Davies M, Khunti K. The association between depression and health-related quality of life in people with type 2 diabetes: a systematic literature review. - PubMed - NCBI. Published 2010. Accessed May 26, 2019. https://www.ncbi.nlm.nih.gov/pubmed/20186998
8. Brown GC, Brown MM, Sharma S, Brown H, Gozum M, Denton P. Quality of life associated with diabetes mellitus in an adult population. J Diabetes Complications. 2000;14(1):18-24.
9. Hirai FE, Tielsch JM, Klein BEK, Klein R. Ten-year change in vision-related quality of life in type 1 diabetes: Wisconsin epidemiologic study of diabetic retinopathy. Ophthalmology. 2011;118(2):353-358. doi:10.1016/j.ophtha.2010.06.022
10. Yang XF, You R, Zhao L, Chen X, Guo XX, Wang YL. [Analysis of the quality of life and the influencing factors in patients with diabetic retinopathy before and after receiving pan-retinal photocoagulation]. Zhonghua Yan Ke Za Zhi Chin J Ophthalmol. 2018;54(8):611-616. doi:10.3760/cma.j.issn.0412-4081.2018.08.009
11. Trento M, Raballo M, Trevisan M, et al. A cross-sectional survey of depression, anxiety, and cognitive function in patients with type 2 diabetes. Acta Diabetol. 2012;49(3):199-203. doi:10.1007/s00592-011-0275-z
12. Cosci F, Fava GA, Sonino N. Mood and Anxiety Disorders as Early Manifestations of Medical Illness: A Systematic Review. Psychother Psychosom. 2015;84(1):22-29. doi:10.1159/000367913
13. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160(14):2101-2107.
14. Olson D, Zhang X, Ward MF, et al. Rates of Comorbid Anxiety and Depression in Patients With Age-Related Macular Degeneration. J Vitreoretin Dis. 2019;3(4):211-214. doi:10.1177/2474126419849199
15. Zhang X, Olson DJ, Le P, Lin FC, Fleischman D, Davis RM. The Association Between Glaucoma, Anxiety, and Depression in a Large Population. Am J Ophthalmol. 2017;183:37-41. doi:10.1016/j.ajo.2017.07.021
16. van der Vaart R, Weaver MA, Lefebvre C, Davis RM. The Association Between Dry Eye Disease and Depression and Anxiety in a Large Population-Based Study. Am J Ophthalmol. 2015;159(3):470-474. doi:10.1016/j.ajo.2014.11.028
17. Rajput R, Gehlawat P, Gehlan D, Gupta R, Rajput M. Prevalence and predictors of depression and anxiety in patients of diabetes mellitus in a tertiary care center. Indian J Endocrinol Metab. 2016;20(6):746. doi:10.4103/2230-8210.192924
18. Poongothai S, Anjana RM, Pradeepa R, et al. Association of Depression with Complications of Type 2 Diabetes – The Chennai Urban Rural Epidemiology Study (CURES- 102). 2011;59:5.
19. Miyaoka Y, Miyaoka H, Motomiya T, Kitamura S, Asai M. Impact of sociodemographic and diabetes-related characteristics on depressive state among non-insulin-dependent diabetic patients. Psychiatry Clin Neurosci. 1997;51(4):203-206.
20. Öztürk ZA, Yeşil Y, Kuyumcu ME, Kepekçi Y. Association of depression and sleep quality with complications of type 2 diabetes in elderly. Eur Geriatr Med. 2013;4:S19. doi:10.1016/j.eurger.2013.07.048
21. Gorska-Ciebiada M, Saryusz-Wolska M, Ciebiada M, Loba J. Mild Cognitive Impairment and Depressive Symptoms in Elderly Patients with Diabetes: Prevalence, Risk Factors, and Comorbidity. J Diabetes Res. 2014;2014:1-7. doi:10.1155/2014/179648
22. Xu X, Zhao X, Qian D, Dong Q, Gu Z. Investigating Factors Associated with Depression of Type 2 Diabetic Retinopathy Patients in China. PloS One. 2015;10(7):e0132616. doi:10.1371/journal.pone.0132616
23. Jafarinezhad A, Zohrevand B, Kalantari S. Association of depression with type 2 diabetes and relevant factors. Adv Biomed Res. 2014;3(1):244. doi:10.4103/2277-9175.145753
24. Le Floch JP, Doucet J, Bauduceau B, Verny C, SFD/SFGG Intergroup. Retinopathy, nephropathy, peripheral neuropathy and geriatric scale scores in elderly people with Type 2 diabetes. Diabet Med. 2014;31(1):107-111. doi:10.1111/dme.12327
25. Mazhar K, Varma R, Choudhury F, et al. Severity of diabetic retinopathy and health-related quality of life: the Los Angeles Latino Eye Study. Ophthalmology. 2011;118(4):649-655. doi:10.1016/j.ophtha.2010.08.003
26. Fenwick EK, Pesudovs K, Khadka J, et al. The impact of diabetic retinopathy on quality of life: qualitative findings from an item bank development project. Qual Life Res Int J Qual Life Asp Treat Care Rehabil. 2012;21(10):1771-1782. doi:10.1007/s11136-012-0110-1
27. Trento M, Passera P, Trevisan M, et al. Quality of life, impaired vision and social role in people with diabetes: a multicenter observational study. Acta Diabetol. 2013;50(6):873-877. doi:10.1007/s00592-013-0470-1
28. Hirai FE, Tielsch JM, Klein BEK, Klein R. Relationship between Retinopathy Severity, Visual Impairment and Depression in Persons with Long-term Type 1 Diabetes. Ophthalmic Epidemiol. 2012;19(4):196-203. doi:10.3109/09286586.2012.692006
29. Granström T, Forsman H, Leksell J, Jani S, Raghib AM, Granstam E. Visual functioning and health-related quality of life in diabetic patients about to undergo anti-vascular endothelial growth factor treatment for sight-threatening macular edema. J Diabetes Complications. 2015;29(8):1183-1190. doi:10.1016/j.jdiacomp.2015.07.026
30. Das T, Wallang B, Semwal P, Basu S, Padhi TR, Ali MH. Changing Clinical Presentation, Current Knowledge-Attitude-Practice, and Current Vision Related Quality of Life in Self-Reported Type 2 Diabetes Patients with Retinopathy in Eastern India: The LVPEI Eye and Diabetes Study. J Ophthalmol. 2016;2016:e3423814. doi:10.1155/2016/3423814
31. Karlson B, Agardh CD. Burden of illness, metabolic control, and complications in relation to depressive symptoms in IDDM patients. Diabet Med J Br Diabet Assoc. 1997;14(12):1066-1072. doi:10.1002/(SICI)1096-9136(199712) 14:12<1066::AID-DIA462>3.0.CO;2-M
32. Lee HJ, Chapa D, Kao CW, et al. Depression, quality of life, and glycemic control in individuals with type 2 diabetes. J Am Acad Nurse Pract. 2009;21(4):214-224. doi:10.1111/j.1745-7599.2009.00396.x
33. Iype T, Shaji SK, Balakrishnan A, Charles D, Varghese AA, Antony TP. Cognition in type 2 diabetes: Association with vascular risk factors, complications of diabetes and depression. Ann Indian Acad Neurol. 2009;12(1):25-27. doi:10.4103/0972-2327.48848
34. Xu X, Zhao X, Qian D, Dong Q, Gu Z. Investigating Factors Associated with Depression of Type 2 Diabetic Retinopathy Patients in China. PloS One. 2015;10(7):e0132616. doi:10.1371/journal.pone.0132616
35. Hirai FE, Tielsch JM, Klein BEK, Klein R. Ten-year change in vision-related quality of life in type 1 diabetes: Wisconsin epidemiologic study of diabetic retinopathy. Ophthalmology. 2011;118(2):353-358. doi:10.1016/j.ophtha.2010.06.022
36. Rees G, Xie J, Fenwick EK, et al. Association Between Diabetes-Related Eye Complications and Symptoms of Anxiety and Depression. JAMA Ophthalmol. 2016;134(9):1007-1014. doi:10.1001/jamaophthalmol.2016.2213
37. Rees G, Xie J, Fenwick EK, et al. Association Between Diabetes-Related Eye Complications and Symptoms of Anxiety and Depression. JAMA Ophthalmol. 2016;134(9):1007-1014. doi:10.1001/jamaophthalmol.2016.2213
38. Fisher L, Skaff MM, Mullan JT, Arean P, Glasgow R, Masharani U. A longitudinal study of affective and anxiety disorders, depressive affect and diabetes distress in adults with Type 2 diabetes. Diabet Med J Br Diabet Assoc. 2008;25 (9):1096-1101. doi:10.1111/j.1464-5491.2008.02533.x
39. Collins MM, Corcoran P, Perry IJ. Anxiety and depression symptoms in patients with diabetes. Diabet Med J Br Diabet Assoc. 2009;26(2):153-161.
doi:10.1111/j.1464-5491.2008.02648.x
40. Henderson AS, Jorm AF, Korten AE, Jacomb P, Christensen H, Rodgers B. Symptoms of depression and anxiety during adult life: evidence for a decline in prevalence with age. Psychol Med. 1998;28(6):1321-1328. doi:10.1017/s0033291798007570
41. Nyman SR, Dibb B, Victor CR, Gosney MA. Emotional well-being and adjustment to vision loss in later life: a meta-synthesis of qualitative studies. Disabil Rehabil. 2012;34(12):971-981. doi:10.3109/09638288.2011.626487
42. Senra H, Balaskas K, Mahmoodi N, Aslam T. Experience of Anti-VEGF Treatment and Clinical Levels of Depression and Anxiety in Patients With Wet Age-Related Macular Degeneration. Am J Ophthalmol. 2017;177:213-224. doi:10.1016/j.ajo.2017.03.005
43. Yu Y, Feng L, Shao Y, et al. Quality of life and emotional change for middle-aged and elderly patients with diabetic retinopathy. Int J Ophthalmol. 2013;6(1):71-74. doi:10.3980/j.issn.2222-3959.2013.01.15
44. Hirai FE, Tielsch JM, Klein BEK, Klein R. Relationship between Retinopathy Severity, Visual Impairment and Depression in Persons with Long-term Type 1 Diabetes. Ophthalmic Epidemiol. 2012;19(4):196-203. doi:10.3109/09286586.2012.692006
45. Radloff LS. The CES-D Scale: A Self-Report Depression Scale for Research in the General Population. Appl Psychol Meas. 1977;1(3):385-401. doi:10.1177/014662167700100306
46. Roberts RE, Kaplan GA, Shema SJ, Strawbridge WJ. Does growing old increase the risk for depression? Am J Psychiatry. 1997;154(10):1384-1390. doi:10.1176/ajp.154.10.1384
47. Borowsky SJ, Rubenstein LV, Meredith LS, Camp P, Jackson-Triche M, Wells KB. Who is at risk of nondetection of mental health problems in primary care? J Gen Intern Med. 2000;15(6):381-388. doi:10.1046/j.1525-1497.2000.12088.x
48. Roy MS, Roy A, Affouf M. Depression is a Risk Factor for Poor Glycemic Control and Retinopathy in African-Americans With Type 1 Diabetes: Psychosom Med. 2007;69(6):537-542. doi:10.1097/PSY.0b013e3180df84e2
49. Yekta Z, Xie D, Bogner HR, et al. The association of antidepressant medications and diabetic retinopathy among people with diabetes. J Diabetes Complications. 2015;29(8):1077-1084. doi:10.1016/j.jdiacomp.2015.06.009