The relationships between depression and disability have important implications for depression treatment strategies. Decisions regarding when to intervene are often based on an assessment of symptom severity, and treatment usually occurs when depression is moderate or severe. However, our research suggests that it might be in the patient’s best interest to intervene early, at a time when symptoms are milder and perhaps more manageable, so that more severe depression and disability can be prevented. This requires broad-based tactics for depression screening with measures that are sensitive enough to capture even a few depressive symptoms.
It is noteworthy that many of the studies discussed above found no relationship between depression and severity of vision loss, suggesting that even patients with mild to moderate vision loss are at risk for depression and subsequent functional impairment. To test the hypothesis that depression is unrelated to the degree of visual impairment, we assessed visual acuity in 32 elderly psychiatric inpatients with major depression. Acuity was assessed at both admission and discharge. Acuity did not change as depression improved, and it was not related to depressive symp toms at either point.18 These results illustrate not only that visual acuity mea sures are unaffected by depression but also that degree of vision loss is unrelated to depression.
Depression can also affect the way in which ophthalmologists treat elderly patients with impaired vision. In an unpublished study, we interviewed 100 ophthalmologists to determine their level of awareness of depression in their patients and how it affects their care. While most (96%) recognized that de pression interferes with patients’ functioning, two thirds stated that they do not pursue aggressive treatment in patients with depression, and 28% said that they do not refer patients who are depressed for rehabilitation. Considering the high rate of depression in these patients, as many as one third may not be offered important treatment interventions. This is especially disturbing because rehabilitation, in particular, may have an antidepressant effect.
In a group of older people newly referred for low vision rehabilitation, active participation in rehabilitation was related to a decrease in depressive symptoms over a 2-year period.19 Unlike other diseases of aging that cause depression (stroke, heart disease), the relationship between depression and vision loss is not physiologic in nature. Instead it is probably caused by loss of independence, the relinquishment of valued activities, and a decrease in social activities. Depression can erode feelings of self-efficacy, leaving people with the belief that they cannot accomplish anything. Rehabilitation presents an optimal opportunity to address all these issues and subsequently alleviate depression. Teaching techniques to complete tasks in novel ways may re store feelings of independence and control. In addition, allowing patients to realize that they can still participate in social events and other enjoyable activities is vital to helping them overcome depression.
As awareness of the psychological consequences of vision loss increases, more resources are being devoted to helping patients effectively live with this disability. In a randomized trial, Brody and colleagues20 evaluated a group-level program to improve mood and function in 231 patients with AMD. Their 6-week intervention was led by a health professional and consisted of didactic instruction regarding basic information about AMD and rehabilitative strategies. It also contained a behavioral component that emphasized dealing with some of the challenges presented by AMD. Their data showed that the intervention group evinced a significant improvement in mood 6 weeks after baseline and that this effect was most pronounced for those who met criteria for depression at baseline. Subjects in the intervention group displayed improved function, and again, this effect was most apparent for those with depression. This study clearly demonstrates that both the emotional distress and functional declines that frequently accompany AMD can be improved.
In an attempt to prevent depression and its associated disabling effects, we received a grant from the National Institute of Mental Health to conduct a randomized controlled clinical trial to test the efficacy of a brief cognitive-behavioral therapy—Problem Solving Treatment (PST)—to prevent depression in 230 patients with new-onset bilateral AMD. This study is based on the premise that inaccurate appraisals of problems and dysfunctional problem-solving skills contribute to the on set of depression. It further posits that teaching patients effective problem-solving skills can foster independence, preserve function, and alleviate depressive symptoms.
Patients were randomized to PST or usual care and were monitored for 12 months (2, 6, and 12 months postbaseline). The main outcome was de pression status. Secondary outcomes included vision function (assessed by both self-report and observation) and general function. At this time, the 2-month data are available for analysis, and so far the results are promising. About 12% of the PST group became depressed at 2 months compared with 23% of the usual-care group. There was a parallel group difference in function; 23% of subjects in the PST group relinquished an important activity versus 37% in the usual-care group. These preliminary results indicate that the negative effects of vision loss can potentially be mitigated by improving patients' problem-solving skills.
Implications for practice
The research presented in this review has important implications for the way in which psychiatrists provide care to older patients with vision impairment. A focus on the affective and practical impact of the loss of valued activities may uncover important depressive symptoms and lead to an understanding of how depression can impair daily functioning. Acute changes in vision should prompt an ophthalmologic evaluation. Psychiatrists should also be aware that visually impaired older persons are at risk for visual hallucinations, ie, Charles Bonnet syndrome, and they should routinely query patients about visual misperceptions and hallucinations.21
An awareness of available services (low vision rehabilitation, support groups, mobility training) for the visually impaired and a willingness to en courage patients to pursue them might substantially improve mood and a sense of competence in these patients. Psychoeducational techniques that facilitate the development of effective problem-solving skills, particularly as they pertain to finding novel methods for completing everyday activities, appear to be helpful. If clinically im portant depressive symptoms persist despite these interventions, antidepressant medications may be helpful as well.22 Finally, psychiatrists can increase ophthalmologists' awareness of the importance and adverse effects of depression and collaborate with them to provide optimal care.
Clearly, the effects of vision loss extend well beyond objective visual limitations and involve many aspects of psycho social functioning, particularly mood. Depression commonly accompanies vision loss and is a major contributor to disability. Along these lines, future research should focus on training ophthalmologists to efficiently screen for depressive symptoms and appropriately refer patients with AMD who are depressed for treatment. In addition, new ways, such as the ones described in this article, need to be found to incorporate interventions into routine ophthalmologic care.
Dr Casten is assistant professor in the department of psychiatry and human behavior and Dr Rovner is professor in the departments of psychiatry and human behavior and neurology at Thomas Jefferson University in Philadelphia. They report that they have no conflicts of interest concerning the subject matter of this article.