The relationship between diabetic retinopathy and psychosocial functioning: a systematic review

  • Krystal Khoo
  • Ryan E. K. Man
  • Gwyn Rees
  • Preeti Gupta
  • Ecosse L. LamoureuxEmail author
  • Eva K. Fenwick



Previous work has reported a link between diabetic retinopathy/diabetic macular edema (DR/DME) and psychosocial functioning, although the extent and direction of the association remains uncertain.


To determine the relationship between DR/DME and psychosocial functioning, the latter an umbrella term used to capture the emotional and social aspects of functioning which may include, for example, depression; depressive disorder; anxiety; vision-specific distress; diabetes-specific distress and emotional and social well-being.

Evidence review

PubMed, Embase, Medline and the Cochrane Central register were systematically searched for relevant interventional and observational quantitative studies using standardised criteria. Studies with DR/DME and psychosocial functioning as exposures or outcomes were accepted. Study quality was evaluated using the modified Newcastle–Ottawa scale for observational studies, and the modified Down’s and Black checklist for interventional studies.


Of 1827 titles initially identified, 42 were included in the systematic review. They comprised of four interventions (one RCT, three non-RCTs) and 38 observational studies (33 cross sectional, five prospective). In studies with DR/DME as the exposure (n = 28), its severity and related vision impairment were consistently associated with poor psychosocial outcomes, mostly higher incidence of depression and depressive symptoms. Baseline depression and depressive symptoms were also associated with greater DR incidence and progression of DR. Medical intervention strategies showed significant improvement in psychosocial outcomes in patients with DR, such as significant improvements in mental health domain scores of the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ 25).

Conclusion and relevance

Severity of DR, DME and associated vision loss are significantly associated with poor psychosocial outcomes. Aspects of depression and its symptoms show a bi-directional association, with increased incidence and progression of DR significant in those with baseline depression or depressive symptoms. Based on these findings, we propose two areas that may benefit from targeted interventions: (1) Prevention of development of poor psychological outcomes by preventing and delaying progression of DR/DME; and (2) Improved detection and management of poor psychological functioning by improving screening tools and multidisciplinary care for patients. Subsequent longitudinal studies can further help establish the underlying relationship between the two measures.


Diabetic retinopathy Depression Quality of life Vision impairment Psychosocial 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Supplementary material

11136_2019_2165_MOESM1_ESM.doc (64 kb)
Supplementary material 1 (DOC 64 KB)
11136_2019_2165_MOESM2_ESM.pdf (192 kb)
Supplementary material 2 (PDF 191 KB)


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
  2. 2.Singapore Eye Research Institute (SERI)SingaporeSingapore
  3. 3.Duke–National University of Singapore Medical SchoolSingaporeSingapore
  4. 4.Centre for Eye Research Australia, Royal Victorian Eye and Ear HospitalUniversity of MelbourneMelbourneAustralia

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