Design and Validation of an AI-Assisted Sequential Screening Framework for Psychological Distress in Glaucoma
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Purpose
Psychological distress is highly prevalent in glaucoma and is associated with worse adherence, reduced quality of life, and faster disease progression. However, distress is rarely assessed in ophthalmology settings due to time, workflow, and staffing constraints. We evaluated two artificial intelligence (AI)-based screening strategies, designed to efficiently identify distressed primary open angle glaucoma (POAG) patients during routine care, aiming to achieve effective, resource conscious, low burden clinical screening.
Design
Hybrid retrospective cohort and prospective cross-sectional study.
Participants
The retrospective cohort included >3,000 POAG patients from the Duke Ophthalmic Registry. Prospective validation was conducted in a separate 300 POAG patient cohort who completed patient-reported distress screening.
Methods
Using retrospective data, a neural network model was trained to predict an electronic health record (EHR)-derived computable phenotype of distress (“silver standard”). Prospective validation used the 8-item Patient Health Questionnaire (PHQ-8) as the “gold standard.” Three screening strategies were compared against PHQ-8: (1) universal PHQ-2 screening (two-item screener administered to all patients), (2) AI-only screening (fully automated EHR-based screener), and (3) sequential screening, (only patients flagged as high risk by AI screener completed the PHQ-2). Performance metrics included sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and screening burden.
Main Outcome Measures
Sensitivity; specificity; PPV; NPV; accuracy; proportion of patients requiring secondary screening (screening burden).
Results
Distress prevalence was 17% (PHQ-8 > 6). Universal PHQ-2 screening (> 0) achieved high sensitivity (0.96) but lower specificity (0.73) and PPV (0.41), while requiring screening of all patients. The AI-assisted sequential approach substantially reduced screening burden while maintaining strong diagnostic performance. By administering PHQ-2 to ∼25% of patients, sequential screening achieved sensitivity 0.64, specificity 0.93, PPV 0.64, NPV 0.93, and accuracy 0.88, representing a ∼50% increase in PPV compared to PHQ-2 alone. AI-only screening reduced burden further but did not achieve comparable sensitivity or predictive performance.
Conclusions
AI-assisted sequential screening enables scalable, resource efficient identification of psychological distress in glaucoma care, substantially reducing screening burden while preserving clinically meaningful performance. This framework offers a practical pathway for integrating distress screening into routine ophthalmology workflows and improving the identification and referral of at-risk patients.
