Depressive symptoms, resilience, and personality traits in dry eye disease

  • Tina KaiserEmail author
  • Birgit Janssen
  • Stefan Schrader
  • Gerd Geerling



Dry eye disease (DED) is a multifactorial disease of the ocular surface that leads to symptoms of discomfort and reduces quality of life. Several studies have shown an association with depression. We investigated the prevalence of depressive symptoms and their severity in DED patients and examined whether depressive symptoms correlate with signs, symptoms, or subtypes of DED or with psychological factors (resilience, premorbid personality, and subjective well-being).


This cross-sectional study (n = 64, mean age 56.72, 70% women) was conducted at the Dry Eye Clinic of the Department of Ophthalmology, University Hospital Düsseldorf. Psychological assessment included the Beck Depression Inventory, revised version (BDI-II); World Health Organization Well-Being Index (WHO-5); 13-item Resilience Scale (RS-13); and Munich Personality Test (MPT). DED parameters were assessed by the Ocular Surface Disease Index (OSDI), Schirmer test (ST), tear film break-up time (TBUT), and corneal fluorescein staining (CFS). As the reference for the BDI-II depression score, we used standard values from a German sample of healthy individuals (n = 582, 66% women). Multivariate logistic regression analysis was performed to investigate the effects of various parameters on depressive symptoms. Associations between variables were examined by Pearson or Spearman correlation tests.


Among all participants, 61% had depressive symptoms (25% minimal, 14% mild, 17% moderate, and 5% severe). The mean BDI-II score (11.95, ± 8.46) was significantly higher than in the healthy reference group (p < .0001). It was not correlated with the severity of signs or symptoms of DED or with its subtypes, but it was significantly negatively correlated with resilience (p < .0001) and subjective well-being (p < .0001). Depressive symptoms were negatively correlated with the premorbid personality trait extraversion (p = .036) and frustration tolerance (p < .0001) and positively correlated with premorbid neuroticism (p = .001), isolation tendencies (p = .014), and esoteric tendencies (p = .001).


Depressive symptoms of all degrees of severity are common in DED patients, but they are not associated with the severity of signs or symptoms of DED. Subjective well-being, resilience, and premorbid personality do not correlate with the signs or symptoms of DED, but they do correlate with depressive symptoms.


Dry eye disease Depression Depressive symptoms Resilience Personality traits Beck Depression Inventory 



The authors thank Jacquie Klesing, the Board-certified Editor in the Life Sciences (ELS), for editing assistance with the manuscript.

Compliance with ethical standards

This cross-sectional study was approved by the ethics committee of the Medical Faculty of the Heinrich-Heine University Düsseldorf, Germany.

Conflict of interests

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants in the study.


  1. 1.
    Craig JP, Nichols KK, Akpek EK et al (2017) TFOS DEWS II definition and classification report. Ocul Surf 15(3):276–283CrossRefGoogle Scholar
  2. 2.
    Mertzanis P, Abetz L, Rajagopalan K et al (2005) The relative burden of dry eye in patients’ lives: comparisons to a U.S. normative sample. Invest Ophthalmol Vis Sci 46(1):46–50CrossRefGoogle Scholar
  3. 3.
    Miljanovic B, Dana R, Sullivan DA et al (2007) Impact of dry eye syndrome on vision-related quality of life. Am J Ophthalmol 143(3):409–415CrossRefGoogle Scholar
  4. 4.
    McCarty CA, Bansal AK, Livingston PM et al (1998) The epidemiology of dry eye in Melbourne, Australia. Ophthalmology 105(6):1114–1119CrossRefGoogle Scholar
  5. 5.
    Hashemi H, Khabazkhoob M, Kheirkhah A et al (2014) Prevalence of dry eye syndrome in an adult population. Clin Exp Ophthalmol 42(3):242–248CrossRefGoogle Scholar
  6. 6.
    Jie Y, Xu L, Wu YY et al (2009) Prevalence of dry eye among adult Chinese in the Beijing Eye Study. Eye (Lond) 23(3):688–693CrossRefGoogle Scholar
  7. 7.
    Yazdani C, McLaughlin T, Smeeding JE et al (2001) Prevalence of treated dry eye disease in a managed care population. Clin Ther 23(10):1672–1682CrossRefGoogle Scholar
  8. 8.
    Stapleton F, Alves M, Bunya VY et al (2017) TFOS DEWS II epidemiology report. Ocul Surf 15(3):334–365CrossRefGoogle Scholar
  9. 9.
    Schiffman RM, Walt JG, Jacobsen G et al (2003) Utility assessment among patients with dry eye disease. Ophthalmology 110(7):1412–1419CrossRefGoogle Scholar
  10. 10.
    Buchholz P, Steeds CS, Stern LS et al (2006) Utility assessment to measure the impact of dry eye disease. Ocul Surf 4(3):155–161CrossRefGoogle Scholar
  11. 11.
    Kim KW, Han SB, Han ER et al (2011) Association between depression and dry eye disease in an elderly population. Invest Ophthalmol Vis Sci 52(11):7954–7958CrossRefGoogle Scholar
  12. 12.
    Wen W, Wu Y, Chen Y et al (2012) Dry eye disease in patients with depressive and anxiety disorders in Shanghai. Cornea 31(6):686–692CrossRefGoogle Scholar
  13. 13.
    Labbe A, Wang YX, Jie Y et al (2013) Dry eye disease, dry eye symptoms and depression: the Beijing Eye Study. Br J Ophthalmol 97(11):1399–1403CrossRefGoogle Scholar
  14. 14.
    Galor A, Felix ER, Feuer W et al (2015) Dry eye symptoms align more closely to non-ocular conditions than to tear film parameters. Br J Ophthalmol 99(8):1126–1129CrossRefGoogle Scholar
  15. 15.
    Na K-S, Han K, Park Y-G et al (2015) Depression, stress, quality of life, and dry eye disease in Korean women: a population-based study. Cornea 34(7):733–738CrossRefGoogle Scholar
  16. 16.
    Nepp J (2016) Psychosomatic aspects of dry eye syndrome/Psychosomatische Aspekte beim trockenen Auge. Ophthalmologe 113(2):111–119CrossRefGoogle Scholar
  17. 17.
    Erb C, Horn A, Günthner A et al (1996) Psychosomatic aspects of patients with primary keratoconjunctivitis sicca (Psychosomatische Aspekte bei Patienten mit primarer Keratoconjunctivitis sicca). Klin Monatsbl Augenheilkd 208(2):96–99CrossRefGoogle Scholar
  18. 18.
    Li M, Gong L, Sun X et al (2011) Anxiety and depression in patients with dry eye syndrome. Curr Eye Res 36(1):1–7CrossRefGoogle Scholar
  19. 19.
    Galor A, Feuer W, Lee DJ et al (2012) Depression, post-traumatic stress disorder, and dry eye syndrome: a study utilizing the national United States Veterans Affairs administrative database. Am J Ophthalmol 154(2):340–346.e2CrossRefGoogle Scholar
  20. 20.
    Yilmaz U, Gokler ME, Unsal A (2015) Dry eye disease and depression-anxiety-stress: a hospital-based case control study in Turkey. Pak J Med Sci 31(3):626–631Google Scholar
  21. 21.
    van der Vaart R, Weaver MA, Lefebvre C et al (2015) The association between dry eye disease and depression and anxiety in a large population-based study. Am J Ophthalmol 159(3):470–474CrossRefGoogle Scholar
  22. 22.
    Ayaki M, Kawashima M, Negishi K et al (2016) Sleep and mood disorders in dry eye disease and allied irritating ocular diseases. Sci Rep 6:22480CrossRefGoogle Scholar
  23. 23.
    Szakats I, Sebestyen M, Nemeth J et al (2016) The role of health anxiety and depressive symptoms in dry eye disease. Curr Eye Res 41(8):1044–1049CrossRefGoogle Scholar
  24. 24.
    Liyue H, Chiang PP-C, Sung SC et al (2016) Dry eye-related visual blurring and Irritative symptoms and their association with depression and anxiety in eye clinic patients. Curr Eye Res 41(5):590–599CrossRefGoogle Scholar
  25. 25.
    Hallak JA, Tibrewal S, Jain S (2015) Depressive symptoms in patients with dry eye disease: a case-control study using the Beck Depression Inventory. Cornea 34(12):1545–1550CrossRefGoogle Scholar
  26. 26.
    Wan KH, Chen LJ, Young AL (2016) Depression and anxiety in dry eye disease: a systematic review and meta-analysis. Eye (Lond) 30(12):1558–1567CrossRefGoogle Scholar
  27. 27.
    Zheng Y, Wu X, Lin X et al (2017) The prevalence of depression and depressive symptoms among eye disease patients: a systematic review and meta-analysis. Sci Rep 7:46453CrossRefGoogle Scholar
  28. 28.
    Miller KL, Walt JG, Mink DR et al (2010) Minimal clinically important difference for the ocular surface disease index. Arch Ophthalmol 128(1):94–101CrossRefGoogle Scholar
  29. 29.
    Hautzinger M, Keller F, Kühner C (2009) BDI-II. Beck Depressions-Inventar. Revision 2. Auflage. Pearson Assessment, FrankfurtGoogle Scholar
  30. 30.
    Kühner C, Bürger C, Keller F et al (2007) Reliability and validity of the revised Beck Depression Inventory (BDI-II). Results from German samples (Reliabilitat und Validitat des revidierten Beck-Depressions-inventars (BDI-II). Befunde aus deutschsprachigen Stichproben). Nervenarzt 78(6):651–656CrossRefGoogle Scholar
  31. 31.
    Alexandrowicz RW, Fritzsche S, Keller F (2014) Die Anwendbarkeit des BDI-II in klinischen und nichtklinischen Populationen aus psychometrischer Sicht. Eine vergleichende analyse mit dem Rasch-Modell (A psychometric view on the applicability of the BDI-II in non-clinical populations). Neuropsychiatr 28(2):63–73CrossRefGoogle Scholar
  32. 32.
    Topp CW, Østergaard SD, Søndergaard S et al (2015) The WHO-5 well-being index: a systematic review of the literature. Psychother Psychosom 84(3):167–176CrossRefGoogle Scholar
  33. 33.
    Brähler E, Mühlan H, Albani C et al (2007) Teststatistische Prüfung und Normierung der deutschen Versionen des EUROHIS-QOL Lebensqualität-Index und des WHO-5 Wohlbefindens-Index. Diagnostica 53(2):83–96CrossRefGoogle Scholar
  34. 34.
    Wagnild GM, Young HM (1993) Development and psychometric evaluation of the Resilience Scale. J Nurs Meas 1(2):165–178Google Scholar
  35. 35.
    Leppert K, Koch B, Brähler E et al (2008) Die Resilienzskala (RS)—Überprüfung der Langform RS-25 und einer Kurzform RS-13. Klin Diagn Eval 2:226–243Google Scholar
  36. 36.
    van Zerssen D, Petermann F (2012) MPT Münchner Persönlichkeitstest. 1. Auflage 2012. HogrefeGoogle Scholar
  37. 37.
    Costa PT, McCrae RR (1992) The five-factor model of personality and its relevance to personality disorders. J Personal Disord 6:343–359CrossRefGoogle Scholar
  38. 38.
    Baudouin C, Aragona P, van Setten G et al (2014) Diagnosing the severity of dry eye: a clear and practical algorithm. Br J Ophthalmol 98(9):1168–1176CrossRefGoogle Scholar
  39. 39.
    World Health Organization (2017) Depression and other common mental disorders. Global Health Estimates, GenevaGoogle Scholar
  40. 40.
    Tiskaoglu NS, Yazici A, Karlidere T et al (2017) Dry eye disease in patients with newly diagnosed depressive disorder. Curr Eye Res 42(5):672–676CrossRefGoogle Scholar
  41. 41.
    Bartlett JD, Keith MS, Sudharshan L et al (2015) Associations between signs and symptoms of dry eye disease: a systematic review. Clin Ophthalmol 9:1719–1730CrossRefGoogle Scholar
  42. 42.
    Vehof J, Sillevis Smitt-Kamminga N, Nibourg SA et al (2017) Predictors of discordance between symptoms and signs in dry eye disease. Ophthalmology 124(3):280–286CrossRefGoogle Scholar
  43. 43.
    Liu JC, Chang LY, Wu SY et al (2015) Resilience mediates the relationship between depression and psychological health status in patients with heart failure: a cross-sectional study. Int J Nurs Stud 52(12):1846–1853CrossRefGoogle Scholar
  44. 44.
    Strauss B, Brix C, Fischer S et al (2007) The influence of resilience on fatigue in cancer patients undergoing radiation therapy (RT). J Cancer Res Clin Oncol 133(8):511–518CrossRefGoogle Scholar
  45. 45.
    Cal SF, Santiago MB (2013) Resilience in systemic lupus erythematosus. Psychol Health Med 18(5):558–563CrossRefGoogle Scholar
  46. 46.
    DeNisco S (2011) Exploring the relationship between resilience and diabetes outcomes in African Americans. J Am Acad Nurse Pract 23(11):602–610CrossRefGoogle Scholar
  47. 47.
    Girtler N, Casari E-F, Brugnolo A et al (2010) Italian validation of the Wagnild and Young resilience scale: a perspective to rheumatic diseases. Clin Exp Rheumatol 28(5):669–678Google Scholar
  48. 48.
    Zautra AJ, Arewasikporn A, Davis MC (2010) Resilience: promoting well-being through recovery, sustainability, and growth. Res Hum Dev 7(3):221–238CrossRefGoogle Scholar
  49. 49.
    Katon W, Kleinman A, Rosen G (1982) Depression and somatization: a review. Am J Med 72(1):127–135CrossRefGoogle Scholar
  50. 50.
    Kawashima M, Uchino M, Yokoi N et al (2015) Associations between subjective happiness and dry eye disease: a new perspective from the Osaka study. PLoS One 10(4):e0123299CrossRefGoogle Scholar
  51. 51.
    Fine PG (2011) Long-term consequences of chronic pain: mounting evidence for pain as a neurological disease and parallels with other chronic disease states. Pain Med 12(7):996–1004CrossRefGoogle Scholar
  52. 52.
    Mathews PM, Ramulu PY, Swenor BS et al (2017) Functional impairment of reading in patients with dry eye. Br J Ophthalmol 101(4):481–486CrossRefGoogle Scholar
  53. 53.
    Arya S, Lee S, Zahner GJ et al (2018) The association of comorbid depression with mortality and amputation in veterans with peripheral artery disease. J Vasc Surg 68(2):536–545.e2CrossRefGoogle Scholar
  54. 54.
    Donnellan C, Hickey A, Hevey D et al (2010) Effect of mood symptoms on recovery one year after stroke. Int J Geriatr Psychiatry 25(12):1288–1295CrossRefGoogle Scholar
  55. 55.
    Baumeister H, Hutter N, Bengel J (2012) Psychological and pharmacological interventions for depression in patients with diabetes mellitus and depression. Cochrane Database Syst Rev 12:CD008381Google Scholar
  56. 56.
    DGPPN, BÄK, KBV et al. (2015) S3-Leitlinie/Nationale VersorgungsLeitlinie Unipolare Depression – Langfassung, 2. Auflage. Version 5Google Scholar
  57. 57.
    DiMatteo MR, Lepper HS, Croghan TW (2000) 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 160(14):2101–2107CrossRefGoogle Scholar
  58. 58.
    Clarke DM, Currie KC (2009) Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence. Med J Aust 190(7 Suppl):S54–S60Google Scholar
  59. 59.
    Ghio L, Gotelli S, Cervetti A et al (2015) Duration of untreated depression influences clinical outcomes and disability. J Affect Disord 175:224–228CrossRefGoogle Scholar
  60. 60.
    Ghio L, Gotelli S, Marcenaro M et al (2014) Duration of untreated illness and outcomes in unipolar depression: a systematic review and meta-analysis. J Affect Disord 152-154:45–51CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Psychiatry and Psychotherapy, Medical FacultyHeinrich-Heine-UniversityDüsseldorfGermany
  2. 2.Department of Psychiatry and PsychotherapyLVR-Klinik LangenfeldLangenfeldGermany
  3. 3.Department of OphthalmologyPius-Hospital OldenburgOldenburgGermany
  4. 4.Department of OphthalmologyUniversity Hospital Düsseldorf, Heinrich-Heine-UniversityDüsseldorfGermany

Personalised recommendations