Vision Impairment Associated with Symptoms of Depression, Anxiety


Worse examination-based and self-reported vision impairment was associated with depressive and anxiety symptoms among adults aged ≥65 years.

Pradeep Y. Ramulu, MD, MHS, PhD | Image Credit: Johns Hopkins Medicine

Pradeep Y. Ramulu, MD, MHS, PhD

Credit: Johns Hopkins Medicine

A new study linked vision impairment to various psychosocial outcomes, including symptoms of depression and anxiety and measures of social isolation, among US adults aged 65 years and older.1

The cross-sectional analysis used two rounds (2019, 2021) from the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries. These data showed adults with either objectively measured vision impairment or self-reported vision impairment exhibited a greater likelihood of depressive and anxiety symptoms, as well as severe social isolation.

“While maintaining eye health will always be important, these findings provide evidence to support prioritizing research aimed at enhancing the health and inclusion of people with vision impairment,” wrote the investigative team led by Pradeep Y. Ramulu, MD, MHS, PhD, Wilmer Eye Institute, Johns Hopkins University School of Medicine.

Vision impairment creates barriers to healthcare access due to patient- and system-level factors, ranging from social determinants of health to inadequate insurance coverage.2 A delay in medical care and necessary prescription can be a notable detriment to health, leading to undesirable patient effects, including psychosocial implications. Wide-ranging consequences of the COVID-19 pandemic increased the number of adults experiencing impaired psychological and social functioning.3

Evidence linking objectively measured visual function to depressive symptoms is inconclusive—Ramulu and colleagues indicated the importance of calculating updated national estimates on the associations between psychosocial functioning and objectively- and self-reported vision impairment.1 To evaluate that impact, the team studied the association between vision impairment and psychosocial function before and after the onset of the COVID-19 pandemic.

In NHATS rounds 9 (2019) and 11 (2021), the survey tested binocular distance visual acuity, near visual acuity, and contrast sensitivity. Objectively measured vision impairment was defined as an impairment in either distance visual acuity (<0.3 logMAR or <20/40), near visual acuity (<0.3 logMAR or <20/40), or contrast sensitivity (<1.55 logCS). Self-reported visual impairment was dependent on participants’ or their proxy's report on vision status.

Depressive and anxiety symptoms were measured using the Patient Health Questionnaire for Depression and Anxiety (PHQ-4). A 4-point Likert scale (0 to 4) measured depression and anxiety experiences, with higher scores indicating more severe depressive and anxiety symptoms. Social isolation was assessed according to living arrangement, communication frequency, and activity participation in the past month.

The analysis included 2822 community-dwelling adults representing a population of 26,182,090 US adults—the population had a mean age of 78.5 years, and 1605 individuals (54.7%) were female. Of the study population, 1077 (32.3%) had objectively measured vision impairment and 203 (6.4%) had self-reported vision impairment.

After multivariable logistic regression analysis, investigators found all outcomes were more frequently associated with objectively measured vision impairment. These associations included depressive symptoms (odds ratio [OR], 1.81; 95% CI, 1.26 - 2.58), anxiety symptoms (OR, 1.74; 95% CI, 1.13 - 2.67), and severe social isolation (OR, 2.01; 95% CI, 1.05 - 3.87).

Depressive symptoms (OR, 2.37; 95% CI, 1.44 - 3.88) and anxiety symptoms (OR, 2.10; 95% CI, 1.09 - 4.05) were also more frequently present in people with self-reported vision impairment. However, severe social isolation symptoms were not significantly associated with self-reported impairment (OR, 2.07; 95% CI, 0.78 - 5.49).

Across the adjusted models, Ramulu and colleagues found the COVID-19 pandemic was associated with an increased likelihood of reporting anxiety symptoms and the risk of social isolation. However, the team identified no associations between the pandemic and depressive symptoms and severe social isolation.

Ramulu and colleagues indicated the connection between vision impairment and psychosocial may not be a result of vision loss alone— they indicated environmental challenges and inequities in access play an important role in the association.

“These findings suggest that additional longitudinal studies are needed to enhance our understanding of these associations and to determine the influence of environmental factors on them,” investigators wrote.


  1. Almidani L, Miller R, Varadaraj V, Mihailovic A, Swenor BK, Ramulu PY. Vision Impairment and Psychosocial Function in US Adults. JAMA Ophthalmol. Published online February 22, 2024. doi:10.1001/jamaophthalmol.2023.6943
  2. Kumar P, Brinson J, Wang J, et al. Self-Reported Vision Impairment and Food Insecurity in the US: National Health Interview Survey, 2011-2018. Ophthalmic Epidemiol. 2023;30(5):468-476. doi:10.1080/09286586.2022.2129698
  3. Su Y, Rao W, Li M, Caron G, D'Arcy C, Meng X. Prevalence of loneliness and social isolation among older adults during the COVID-19 pandemic: A systematic review and meta-analysis. Int Psychogeriatr. 2023;35(5):229-241. doi:10.1017/S104161022200019
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