Clinical science

Influence of visual acuity on suicidal ideation, suicide attempts and depression in South Korea Tyler Hyungtaek Rim,1 Christopher Seungkyu Lee,1 Sung Chul Lee,1 Byunghoon Chung,1 Sung Soo Kim,1,2,3 Epidemiologic Survey Committee of the Korean Ophthalmological Society ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ bjophthalmol-2014-306518). 1

Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea 2 Yonsei healthcare Big Data based Knowledge Integration System Research Center, Yonsei University College of Medicine, Seoul, Korea 3 Institute of Convergence Science, Yonsei University College of Medicine, Seoul, Korea Correspondence to Professor Sung Soo Kim, Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea; [email protected] Received 15 December 2014 Revised 21 January 2015 Accepted 3 February 2015 Published Online First 2 March 2015

ABSTRACT Background To assess the influence of visual acuity (VA) on suicidal ideation, suicide attempts and depression. Methods From 2008 to 2012, a total of 28 919 nationally representative participants aged 19 years or older in the Korea National Health and Nutrition Examination Survey underwent additional ophthalmological examinations by the Korean Ophthalmologic Society. Associations between best corrected VA in the betterseeing eye based on decimal fraction and mental health were identified using multivariable logistic regression analysis after adjusting for possible biopsychosocial confounders. Self-reported mental health (suicidal ideation, suicide attempt and depression), Euro Quality of Life-Visual Analog Scale and counselling experience were evaluated by direct interviews. A nomogram for risk of suicidal ideation was generated. Results By multivariable logistic regression analysis, low VA was significantly associated with suicidal ideation and suicide attempt but not depression. Participants with a VA of no light perception to 0.2 had a nearly twofold and threefold increased risk of suicidal ideation (adjusted OR, 1.85; 95% CI 1.04 to 3.27) and suicidal attempt (adjusted OR, 3.44; 95% CI 0.92 to 12.79), compared with participants with a VA of 1.0. Sociodemographic disparities, including age and socioeconomic status, existed for suicidal ideation, suicidal attempt and depression. Euro Quality of Life-Visual Analog Scale significantly decreased as VA decreased and was lower in participants who attempted suicide. Conclusions Low VA was associated with the occurrence of suicidal ideation or a suicide attempt. Ophthalmologists should embrace their responsibility to help reduce suicidality and prevent suicides in patients with low VA by encouraging them to seek psychiatric care.

higher than in Asia or the USA.5 Reduced visual acuity (VA) influences mental health, including the occurrence of depression6–9 and suicidality,10–12 and also the quality of life.13 14 However, the evidence supporting these statements is derived from studies that have limitations, such as focusing on specific age groups, using only small samples, and/ or focusing on the relationship between suicidality and other risk factors, such that VA was not the main factor being investigated and it was considered as simply a component of sensory impairment. The Korea National Health and Nutrition Examination Survey (KNHANES) is a nationally representative survey conducted by the Ministry of Health and Welfare, which provides data on vision status, healthcare use and other sociodemographic factors. The results and statistics of KNHANES are readily available at http://knhanes.cdc.go.kr. Our objective was to use ophthalmological examination results from KNHANES to evaluate the influence of VA on self-reported mental health (including suicidal ideation, suicide attempts and depression) and the quality of life in the Korean population aged 19 years and older.

METHODS Statement of ethics Tenets of the Declaration of Helsinki for biomedical research were followed. Written informed consent was obtained from each participant. Institutional review board approval was granted by the Institutional Review Board of the Korea Centers for Disease Control and Prevention. The design of this study was approved by the institutional review board of Severance Hospital, Yonsei University College of Medicine in Seoul, Korea.

INTRODUCTION

To cite: Rim TH, Lee CS, Lee SC, et al. Br J Ophthalmol 2015;99: 1112–1119. 1112

The concept of suicide includes a spectrum of conditions from suicidal ideation to attempted suicide and suicidal behaviour.1 In 2009, the average mortality rate from suicide in the Organization for Economic Co-operation and Development member countries was 12.8 individuals per 100 000 population.2 Suicide is generally considered as an enormous yet largely preventable public health problem by WHO.3 Visual impairment is also an important health issue, and approximately 14 million individuals aged 12 years or older in the USA had visual impairment in 2006.4 In our previous study, we found that the overall prevalence of visual impairment (acuity ≤20/40) in adults 40 years and older was 4.1% in Korea in 2008–2010, which was

Study design and population Detailed descriptions of patient sampling, enumeration, VA testing and ocular examination procedures have already been published.15 Briefly, the Korea Center for Disease Control and Prevention conducted a series of KNHANESs in 1998, 2001, 2005, 2007–2009 and 2010–2012, and a sixth survey began in 2013. The purpose of these surveys was to examine the general health and nutrition status of Koreans. Annually, 4000 households in 200 enumeration districts were selected by a panel to represent the civilian, non-institutionalised South Korean population, using the stratified multistage cluster sampling method based on National Census data. In KNHANES, sample design and size are estimated so

Rim TH, et al. Br J Ophthalmol 2015;99:1112–1119. doi:10.1136/bjophthalmol-2014-306518

Clinical science that annual survey results represent the entire Korean population. The KNHANES was divided into three parts: the Health Interview Survey, the Health Examination Survey and the Nutrition Survey. For the Health Interview Survey, a trained interviewer directly asked individuals 12 years of age or older a series of questions. Since the Korean Ophthalmologic Society began to participate in this survey in July 2008, the survey participants also underwent ophthalmological interviews and examinations. All members of each selected household were asked to participate in the survey, and the rate of participation was 74.3% in 2008, 79.2% in 2009, 77.5% in 2010, 76.1% in 2011 and 75.9% in 2012. The ophthalmological survey was designed to continue for 5 years, from July 2008 to July 2012. The present study includes all results of the ophthalmological survey, including data from a survey conducted from July 2008 to December 2012. During this period, 37 845 participants were recruited and received an eye examination. Of these, 29 512 participants over the age of 19 years were selected for this study, but 593 participants had incomplete VA testing, so they were subsequently excluded. A total of 28 919 participants were thus included in this study.

VA testing Uncorrected VA and/or best corrected visual acuity (BCVA) was measured at a distance of 4 m using an international standard vision chart based on decimal fractions ( Jin’s vision chart, Seoul, Korea).16 The participant’s VA was measured in each eye, right followed by left. If the participant had an existing refractive correction device, this was worn during the assessment. The participant was asked to read the numbers starting at 0.2, proceeding to the next line if he or she read more than three of the five letters correctly. VA was defined as the line with the smallest numbers in which more than three letters were read correctly. Automated refraction was performed in all participants using the autorefractor-keratometer (KR8800, Topcon, Tokyo, Japan), followed by testing of VA again after applying a pinhole for those patients whose VA was below 0.8 on the decimal fraction. The participant’s VA was defined as the BCVA based on the eye with the best acuity. VA was classified into four strata: 1.0, 0.63–0.8, 0.25–0.5 and no light perception (NLP)–0.2.

Outcome variables Participants over 19 years old were asked the question, ‘Have you ever had suicidal ideation within the past 1 year?’; the possible responses were ‘Yes’ or ‘No’. If participants responded ‘Yes’, they were asked, ‘Have you ever attempted suicide within the past 1 year?’, with the possible responses of ‘Yes’ or ‘No’. This indicator is a well-documented predictor of suicide attempts that has been previously used in other surveys of adults.17 To assess depression, participants were asked the question, ‘Until now, have you ever been diagnosed with a depressive disorder by a doctor?’; the possible responses were ‘Yes’ or ‘No’. To increase the accuracy of the data collection, participants were first asked the question, ‘Until now, have you ever had a depression disorder?’, which was then followed by the above question, with emphasis on ‘by a doctor’. In addition to the aforementioned question that we used to determine the presence of depressive disorder, the survey also contained this question about the presence of a continuous depressive mood for 2 weeks: ‘Have you felt hopelessness or been sad enough that it interfered with your daily life for more than 2 weeks within the past 1 year?’ The Euro Quality of Life-Visual Analog Scale (EQ-VAS) was used for an objective evaluation of the overall health status. EQ-VAS is a standardised, generic

instrument for describing health which was designed by the EuroQol group, an international research network established in 1987.18 The worst health status is represented by a score of ‘0’, and the best health status is represented by a score of ‘100’. To evaluate counselling experience, participants were asked the question, ‘Have you ever had counselling for your psychological problems, via visiting, tele-counselling, internet, etc, within the past 1 year?’; the possible responses were ‘Yes’ or ‘No’.

Independent variables From the KNHANES III and IV data sets, we collected data regarding various sociodemographic factors obtained through direct interviews using standardised questionnaires. The sociodemographic variables were as follows: current age (19–29 years, 30–39 years, 40–49 years, 50–59 years, 60–69 years, 70–79 years or ≥80 years), sex (male or female), monthly household income (lowest quintile, approximately 250), highest educational level reached (elementary school graduate or lower, middle school graduate, high school graduate, or university graduate or higher), occupation (administrator, management or professional; business and financial operations; sales and related occupations; farming, fishing and forestry occupations; installation, maintenance, and repair occupations or technicians; labourer; or unemployed (including housewife)), residential area (urban or rural), spouse (with or without), alcohol use (normal or abnormal) and perceived stress (no, mild, moderate or severe). The income per adult equivalent was calculated using the following formula: household income/square root of number of people in the household.18 Residence was classified as urban or rural depending on whether the administrative district had ≥20 000 or

Influence of visual acuity on suicidal ideation, suicide attempts and depression in South Korea.

To assess the influence of visual acuity (VA) on suicidal ideation, suicide attempts and depression...
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