What are the recommended medications for anxiety and depression in patients with glaucoma?

Recommended Anxiety and Depression Medications for Glaucoma Patients

SSRIs (selective serotonin reuptake inhibitors) are the best first-line medications for anxiety and depression in glaucoma patients, with escitalopram, sertraline, and paroxetine being preferred choices due to their efficacy and lack of anticholinergic effects that could worsen glaucoma. 1, 2

First-Line Pharmacologic Treatment

SSRIs - Preferred Initial Choice

• Escitalopram, sertraline, paroxetine, and fluvoxamine are recommended as first-line treatments for both anxiety and depression in glaucoma patients 1, 3
• These agents have strong evidence supporting their use with a Number Needed to Treat (NNT) of 4.70 for anxiety disorders 1
• SSRIs show similar efficacy across agents for treating depression with comorbid anxiety symptoms 3
• Common side effects include somnolence, dizziness, and nausea, but these do not affect intraocular pressure 1

SNRIs - Effective Alternative

• Venlafaxine is recommended as a first-line alternative with efficacy comparable to SSRIs (NNT = 4.94) 1, 2
• Venlafaxine may be superior to fluoxetine specifically for treating anxiety symptoms 3
• SNRIs have similar dropout rates to placebo, indicating good tolerability 1

Medications to Avoid in Glaucoma Patients

Critical Contraindications

• Avoid tricyclic antidepressants and medications with anticholinergic properties as they can cause pupillary dilation and precipitate angle-closure glaucoma 4, 5
• Antianxiety agents like alprazolam and antidepressants like maprotiline have been documented to precipitate bilateral angle closure glaucoma with severe visual loss 5
• Mirtazapine carries specific warnings about angle-closure glaucoma risk due to mild pupillary dilation effects 4

Benzodiazepines

• While benzodiazepines provide immediate anxiety relief, they should be avoided when possible due to risks of falls, cognitive impairment, and dependence 1
• If benzodiazepines must be used acutely, ensure gradual taper when transitioning to SSRIs/SNRIs 1

Second-Line Options

When First-Line Fails

• Bupropion is an alternative antidepressant that does not have anticholinergic effects, though it carries warnings about increased intraocular pressure and angle-closure glaucoma as rare adverse events 6
• Sedating antidepressants like trazodone or mirtazapine can be considered for comorbid insomnia, but require careful monitoring for angle-closure risk 1, 4
• Duloxetine showed similar efficacy to paroxetine for depression with pain symptoms 3

Special Considerations for Glaucoma Patients

Monitoring Requirements

• Patients should be counseled to report physical or emotional changes when taking topical ocular hypotensive agents 3
• The ophthalmologist should be informed of all psychiatric medications, as some may interact with glaucoma treatments 3
• Patients taking mirtazapine should be examined to determine susceptibility to angle-closure and may need prophylactic iridectomy 4

Psychological Context

• Anxiety prevalence is higher in glaucoma populations (13.0% vs 7.0% in controls), and depression is also elevated (10.9% vs 5.2%) 7
• Anxiety and depression are associated with glaucoma progression, particularly through mechanisms involving IOP fluctuation and disc hemorrhage 8
• Severe/blind stage glaucoma and reduced visual acuity are significantly associated with both anxiety and depression 9

Treatment Algorithm

1. Initiate SSRI therapy: Start with escitalopram, sertraline, or paroxetine at standard doses 1, 2
2. Concurrent CBT referral: Cognitive behavioral therapy should be implemented alongside medication 3, 2
3. Avoid anticholinergic agents: Screen all medications for pupil-dilating effects 4, 5
4. Monitor at 8 weeks: If inadequate response despite good adherence, switch to another SSRI or add venlafaxine 2
5. Coordinate with ophthalmology: Ensure glaucoma specialist is aware of psychiatric medications and monitors for angle changes 3

Common Pitfalls to Avoid

• Never prescribe tricyclic antidepressants or medications with significant anticholinergic properties to glaucoma patients, as these can precipitate acute angle closure 5
• Do not assume topical beta-blockers used for glaucoma cause depression—no significant relationship has been demonstrated 7, 10
• Avoid underutilizing CBT, which has strong evidence for effectiveness and should be offered concurrently with medication 3, 2
• Do not overlook that the psychological burden itself may worsen glaucoma progression through autonomic and IOP mechanisms 8