An eyecare professional talks about the connection between the two, and what optometrists can do to patients struggling with both.
For Megan Zabell, senior professional education and development manager at Alcon, conversations with optometrists rarely stay confined to ocular surface disease alone.
A significant part of her role involves travelling around Australia to speak with optometrists, pharmacists, students and other healthcare professionals about dry eye, contact lenses and the growing list of systemic conditions that influence ocular health.
“I get to travel around and talk to my peers about things like dry eye and contact lenses that I have a passion in,” she says.
In recent years, she has spent a lot of time highlighting the secondary causes of dry eye – from diabetes to menopause – but the link commanding much of her focus now is mental health.
Zabell is having these conversations because many clinicians and patients still underestimate how often dry eye is tied to a broader health issue, including mental health.
Her goal, she says, is simply “to raise awareness and help people realise that these conditions may be linked, and there is something they can do about it”.
Mental health, she argues, is one of the least understood but most clinically relevant of these links.
Around 970 million people globally live with a mental health disorder,1 and in Australia one in five adults has experienced one.2
Research indicates that up to 24% of people with a mental health condition also have dry eye disease3 – a level of comorbidity that makes it one of the most significant ocular surface concerns within this population.3
“It’s well-established that dry eye is more common in patients with a diagnosed mental health disorder,” Zabell says.
But the association goes far deeper than simple overlap. “They’re really well linked. So we know that if someone has depression or anxiety, their dry eye symptoms are probably going to be worse, or . . . have a bigger impact on their quality of life.”
Part of the problem is sensory amplification. People with depression or anxiety “don’t just feel the dry eye as an irritation – it’s something that deeply impacts them”, she says.
Studies support this: depressive patients with dry eye record higher symptom scores and report more severe discomfort than dry eye patients without a mental health diagnosis.5,6
The reverse is also true. People with dry eye are more likely to be depressed or anxious.4
“We can’t say dry eye causes mental health issues, or mental health causes dry eye,”
Zabell says. “We just know they often go hand-in-hand.”
“For patients with depression or anxiety who also experience dry eye symptoms, addressing ocular discomfort with lubricating drops or other dry eye treatments may support overall comfort and quality of life.”
This mutual reinforcement creates a “vicious cycle”5,6 worsening mental health increases pain sensitivity, sleep disturbance and medication load7-12 – all of which can degrade the tear film – while escalating dry eye symptoms feed psychological distress and diminish quality of life.5,6
“People with these mental health disorders often suffer from poor sleep, and that can have an impact on their tear film,” she says. “It’s strongly linked with sleep.”23
Understanding these physiological mechanisms may help clinicians anticipate which patients are at higher risk of mixed or severe dry eye presentations.
An optometrist’s view
Zabell’s comfort moving between clinical, educational and industry settings stems from her background.
“I’m an optometrist by training,” she says.
That clinical grounding shapes the way she frames discussions around systemic links.
Mental-health-associated dry eye is rarely a simple aqueous or evaporative problem; it is more often a mixed dry eye,13 driven by hormonal changes, medication side effects, poor sleep and altered inflammatory responses.23
“These can compound,” she explains, “meaning patients with DED secondary to mental health disorders could potentially affect the tear film in many ways.”
For practitioners, this complexity underscores why treating a single aspect of the tear film may deliver only limited relief.
Yet Zabell is quick to emphasise that the message is not gloomy. “Just because it’s linked, it doesn’t mean, ‘Oh well, I’ve got dry eye because of my mental health. The end.’
There’s always something that can be done to help.”
She believes optometrists are uniquely positioned to identify patients at high risk.
One of the simplest screening tools is already part of every routine consultation: the medication history.
“We always ask what medications someone is taking, so it’s about really thinking of those anti-anxiety or antidepressant medications as a red flag to dive deeper into dry eye symptoms,” she says.
“They can cause dry eye – that’s been identified in the literature,” Zabell notes.
But the interaction is two-way: treating one can sometimes help the other.
“For patients with depression or anxiety who also experience dry eye symptoms, addressing ocular discomfort with lubricating drops or other dry eye treatments may support overall comfort and quality of life, which can be an important component of psychological wellbeing.”
She stresses that no eye drop is a substitute for psychological care, but optometrists can still play a constructive role by spotting patients who might benefit from medical or psychological review.
“It’s not our place to diagnose a mental health disorder,” she says, “but we can recommend that they seek professional support, whether that is with their GP or another health professional.”
This approach also strengthens interprofessional relationships. “It gives us real opportunity to be holistic practitioners, to tie in with other healthcare branches . . . communicate with their psychiatrist or their GP or their endocrinologist,” she says.
“Early intervention is key – the sooner we can interrupt that vicious cycle, the better.”
Where Systane COMPLETE fits In
As part of Alcon’s professional education team, Zabell acknowledges that lubricants are a central part of these discussions.
The company has been actively exploring how dry eye management strategies can support patients with mental health conditions, and Zabell frequently speaks to pharmacists, optometrists and students about the role of all-in-one lubricants such as Systane COMPLETE.
She says the Systane COMPLETE Lubricant Eye Drops range is designed to relieve all major types of dry eye – aqueous deficient, evaporative and mixed14 – which is particularly relevant for mental-health associated cases, where multiple tear-film layers can be compromised simultaneously.24,25
The formulation contains HP-Guar, which forms a hydrophilic meshwork in the muco-aqueous layer. This matrix then slowly releases lipid nano-droplets, replenishing the lipid layer and restoring stability across all three layers of the tear film.14-21
Clinical data show that more than 63% of patients with higher symptom burden experienced significant relief eight hours after a single dose.14
For mental health patients, the benefit is partly physiological and partly emotional.
“The recommendation of a lubricating eye drop will help your patient know that you’re taking it seriously,” Zabell says.
Many patients with anxiety or depression feel their concerns are easily dismissed – especially when clinical signs appear relatively mild compared to reported discomfort.
A strong recommendation can validate their experience, she says.
Choosing a drop designed to address mixed dry eye is crucial.
“Systane COMPLETE . . . is going to help all layers of their tear film, so it’s going to help, hopefully, really improve those symptoms, whether it’s caused by a lipid layer deficiency or a muco -aqueous layer deficiency,”14 she says.
Zabell emphasises that while lubricants won’t resolve a patient’s mental health disorder, they can meaningfully reduce discomfort, improve daily function and even enhance adherence to psychological treatment plans by easing one part of the burden.
As she puts it, sometimes “helping to relieve their dry eye symptoms . . . can help boost the efficacy” of mental health interventions.22
References:
1. World Health Organization (WHO). Mental disorders. Available at: https://www.who.int/news-room/fact- sheets/detail/mental-disorders. Accessed June 30 2023.
2. AIHW. (2025, 05 20). Prevalence and impact of mental illness. Retrieved 12 2025, from Australian Institute of Health and Welfare – Mental Health: https://www.aihw.gov.au/mental-health/overview/prevalence-and-impactofmental-illness
3. Galor A et al. Depression, post-traumatic stress disorder, and dry eye syndrome: a study utilizing the national United States Veterans Affairs administrative database. Am J Ophthalmol. 2012;154(2):340–346.
4. Kitazawa M et al. The Relationship of Dry Eye Disease with Depression and Anxiety: A Naturalistic Observational Study. Transl Vis Sci Technol. 2018;7(6):35.
5. Hallak JA, Tibrewal S, Jain S. Depressive Symptoms in Patients With Dry Eye Disease: A Case-Control Study Using the Beck Depression Inventory. Cornea. 2015;34(12):1545– 1550.
6. Zheng Y et al. The prevalence of depression and depressive symptoms among eye disease patients: a systematic review and meta-analysis. Sci Rep. 2017;7:46453.
7. Li S et al. Sleep deprivation disrupts the lacrimal system and induces dry eye disease. Exp Mol Med. 2018;50(3):e451
8. Lee YB et al. Sleep Deprivation Reduces Tear Secretion and Impairs the Tear Film. Invest Ophthalmol Vis Sci. 2014;55(6):3525-3531.
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10. Kourbanova K, Alexandre C, Latremoliere A. Effect of sleep loss on pain — New conceptual and mechanistic avenues. Front Neurosci. 2022; 16:1009902.
11. Zhang X et al. Selective Serotonin Reuptake Inhibitors Aggravate DepressionAssociated Dry Eye Via Activating the NF-κB Pathway. Invest Ophthalmol Vis Sci. 2019;60(1):407–419.
12. Koçer E et al. Dry Eye Related to Commonly Used New Antidepressants. J Clin Psychopharmacol. 2015;35(4):411–413.
13. Bron AJ et al. Tear Osmolarity in the Diagnosis of Systemic Dehydration and Dry Eye Disease. Ocul Surf. 2017;15(3):438– 510.
14. Silverstein S et al. Symptom Relief Following a Single Dose of Propylene GlycolHydroxypropyl Guar Nanoemulsion in Patients with Dry Eye Disease: A Phase IV, Multicenter Trial. Clin Ophthalmol Auckl NZ. 2020;14:3167-3177.
15. Srinivasan S, Williams R. Propylene Glycol and Hydroxypropyl Guar Nanoemulsion – Safe and Effective Lubricant Eye Drops in the Management of Dry Eye Disease. Clin Ophthalmol. 2022; 16: 3311-3326.
16. Bickle, K., Miller, J.R., Tauber, J. et al. Multi-symptom Relief with Propylene GlycolHydroxypropyl-Guar.
17. Nanoemulsion Lubricant Eye Drops in Subjects with Dry Eye Disease: A PostMarketing Prospective Study. Ophthalmol Ther 2024; 13: 481–494.
18. Springs CL. Novel hydroxypropyl-guar gellable lubricant eye drops for treatment of dry eye. Adv Ther. 2010 Oct; 27(10): 681-90.
19. Kesavan S, Prud’homme RK. Rheology of guar and (hydroxypropyl) guar crosslinked by borate. Macromolecules. 1992;25(7):2026-2032.
20. Rangarajan R, Ketelson H. Preclinical evaluation of a new hydroxypropyl-guar phospholipid nanoemulsion-based artificial tear formulation in models of corneal epithelium. J Ocul Pharm Ther. 2019;35(1):32-37.
21. Weisenberger K, Fogt N, Fogt J S. Comparison of nanoemulsion and non-emollient artificial tears on tear lipid layer thickness and symptoms. J Optom. 2021;14(1):20-27.
22. Weatherby TJM, Raman VRV, Agius M. Depression and dry eye disease: a need for an interdisciplinary approach?. Psychiatr Danub. 2019;31(Suppl 3):619-621.
23. Ayaki M, Tsubota K, Kawashima M, et al. Invest Ophthalmol Vis Sci. 2018;59(14):DES143–DES150
24. Lee YB, et al. Invest Ophthalmol Vis Sci. 2014;55(6):3525-3531
25. Tang L, et al. Invest Ophthalmol Vis Sci. 2018;59(13):5494–5508
