Integrated Low Vision and Mental Health Treatment Can Reduce or Prevent Depression
by Maureen Duffy
The first clinical trial to examine integrated low vision and mental health treatment – bridging ophthalmology, optometry, psychiatry, psychology, and rehabilitation – has demonstrated that an interdisciplinary rehabilitation program can reduce the incidence of depression by half among older adults with low vision due to age-related macular degeneration (AMD).
Ophthalmology: the Journal
The research, entitled Low Vision Depression Prevention Trial in Age-Related Macular Degeneration, has been published online ahead-of-print on July 9, 2014 in Ophthalmology, the official journal of the American Academy of Ophthalmology.
The authors are Barry W. Rovner, MD; Robin J. Casten, PhD; Mark T. Hegel, PhD; Robert W. Massof, PhD; Benjamin E. Leiby, PhD; Allen C. Ho, MD; and William S. Tasman, MD, who represent the following institutions: Jefferson Medical College, Philadelphia, PA; Dartmouth Medical School, Lebanon, NH; and Johns Hopkins School of Medicine, Baltimore, MD.
About the Research
"Our results emphasize the high risk of depression from AMD, and the benefits of multi-disciplinary treatment that bridges primary eye care, psychiatry, psychology, and rehabilitation," said Barry Rovner, M.D., a professor of psychiatry and neurology at Thomas Jefferson University in Philadelphia.
"The depression is a response to disability, so we reasoned an effective treatment would be to reduce the disability through rehabilitation," Dr. Rovner said. In the Low Vision Depression Prevention Trial (VITAL), he led a team of psychologists, ophthalmologists, optometrists, and occupational therapists to test an approach called behavior activation.
"Behavior activation involves helping people to focus on activities they enjoy, to recognize that loss of those activities can lead to depression, and to re-engage in those activities," said Robin Casten, Ph.D., a co-author and an associate professor of psychiatry and human behavior at Jefferson. Helping people maintain an active social life is an important part of the approach, she said.
The trial recruited 188 participants with bilateral [i.e., in both eyes] AMD from an ophthalmology practice affiliated with Wills Eye Hospital in Philadelphia. The participants were 84 years of age on average, 70 percent were women, and 50 percent lived alone. All had a best-corrected visual acuity of less than 20/70.
Each participant had mild depressive symptoms and was at risk for developing clinical depression, based on a nine-item depression subtest of the Patient Health Questionnaire.
During the trial, each participant had two visits with an optometrist, during which they were prescribed low vision devices, such as hand-held magnifiers. After those initial visits, the participants were randomly divided into two groups for two different interventions (described below).
[After four months], 18 (23.4 percent) in the control group and 11 (12.6 percent) in the behavior activation group developed clinical depression. Behavior activation had the most benefit for participants with the worst vision (less than 20/100), reducing the risk of depression by about 60 percent compared to [the control group].
When the data were adjusted for vision status, physical health, and baseline [depression] score, behavior activation reduced the risk of depression by 50 percent compared to the control treatment.
As described in the Low Vision Depression Prevention Trial for Age Related Macular Degeneration, the two interventions were as follows:
Behavior Activation + Low Vision Rehabilitation (The Active Treatment)
- Also called Collaborative Low Vision Rehabilitation (optometrist and home-based occupational therapist)
- Used low vision clinic-based optometry, plus six in-home occupational therapy visits
- A low vision occupational therapist (OT) delivered Behavior Activation, a psychological treatment to prevent depression.
- The optometrists evaluated vision and magnification needs, prescribed low vision optical devices, and provided the OTs with initial care plans.
- The OTs met with participants in their homes six times over 12 weeks to enhance low vision device use, home modifications, and compensatory strategies, such as increasing social activities, setting personal goals, and breaking goals down into manageable steps.
Supportive Therapy + Low Vision Rehabilitation (The Placebo or Comparison)
- Also called Enhanced Low Vision Rehabilitation (optometrist and home-based Supportive Therapy)
- Used low vision clinic-based optometry, plus six in-home Supportive Therapy sessions over 12 weeks
- Supportive therapy is a placebo treatment that controls for the attention the participants in the active treatment group received.
- [Editor's note: In research terminology, a placebo is an intervention or a drug that has no therapeutic effect or contains no active medication.]
About Low Vision
Low vision is uncorrectable vision loss that interferes with daily living activities. It is better defined in terms of function, rather than [numerical] test results. In other words, low vision is "not enough vision to do whatever it is you need to do," which can vary from person to person.
Most eye care professionals use the term "low vision" to describe permanently reduced vision that cannot be corrected with regular glasses, contact lenses, medicine, or surgery. One of the primary causes of low vision is AMD.
You can learn more about low vision at Low Vision and Legal Blindness Terms and Descriptions and What is a Low Vision Examination? on the VisionAware website.
What are Low Vision Rehabilitation Services?
Vision rehabilitation services enable adults who are blind or have low vision to continue living independently. The terms "vision rehabilitation" and "low vision rehabilitation" include highly trained professionals and comprehensive services that can restore function after vision loss, just as physical therapy restores function after a stroke or other injury.
In addition to the interventions described in the VITAL Trial, the full range of vision rehabilitation services and professionals includes the following:
- Low Vision Therapists: teach the use of residual vision with optical devices, non-optical devices, and assistive technology, and help determine the need for environmental modifications in the home or workplace.
- Vision Rehabilitation Therapists: teach adaptive independent living skills that enable adults to perform a wide range of daily activities, including meal preparation, reading and writing, home repair, personal self-care, and financial management.
- Orientation and Mobility Specialists: teach safe and independent indoor and outdoor travel skills, including the use of a long cane, electronic travel devices, public transportation, human guide techniques, and pre-cane skills.
Additional vision rehabilitation services can include:
- Peer support and counseling: talking with peers, sharing common concerns and frustrations, and finding solutions to vision-related problems
- Vocational rehabilitation: vocational evaluation and training, job training, job modification and restructuring, and job placement
- Veterans' services: vision rehabilitation and related support services for blinded veterans of all ages.
More about the Low Vision Depression Prevention Trial Study Results
From the article abstract:
Purpose: To compare the efficacy of behavior activation + low vision rehabilitation with supportive therapy + low vision rehabilitation to prevent depressive disorders in patients with age-related macular degeneration.
Interventions: Before randomization, all subjects had two outpatient low vision rehabilitation visits, and were then randomized to in-home behavior activation + low vision rehabilitation or supportive therapy + low vision rehabilitation.
Behavior activation is a structured behavioral treatment that aims to increase adaptive behaviors and achieve valued goals. Supportive therapy is a nondirective, psychological treatment that provides emotional support and controls for attention.
Results: At four months, 11 behavior activation + low vision rehabilitation subjects (12.6%) and 18 supportive therapy + low vision rehabilitation subjects (23.4%) developed a depressive disorder.
A mediational analysis suggested that behavioral activation + low vision rehabilitation prevented depression to the extent that it enabled subjects to remain socially engaged.
In addition, behavioral activation + low vision rehabilitation was associated with greater improvements in functional vision than supportive therapy + low vision rehabilitation, although there was no significant between-group difference. There was no significant change or between-group difference in quality of life.
Conclusions: An integrated mental health and low vision intervention halved the incidence of depressive disorders relative to standard outpatient low vision rehabilitation in patients with AMD.
As the population ages, the number of persons with AMD and the adverse effects of comorbid [i.e., coexisting] depression will increase. Promoting interactions between ophthalmology, optometry, rehabilitation, psychiatry, and behavioral psychology may prevent depression in this population.
As summarized by Dr. Barry Rovner in Science Codex, "Our findings demonstrate that referring patients with AMD-related low vision for low vision optometric rehabilitation alone does not fully meet the patients' rehabilitative needs. Although low vision occupational therapists do not currently receive training in mental health care, our results indicate that interdisciplinary care like this could significantly help reduce the incidence of depression in patients with AMD."
Please note: The study is continuing to follow participants to determine if the benefits of treatment are maintained after one year.
How to Locate Low Vision Rehabilitation Services
The VisionAware Directory of Services allows you to browse by state and type of service, including counseling resources, support groups, low vision services, independent living skills, and orientation and mobility. The VisionAware "Getting Started" kit provides tip sheets on specialized services and products that can assist with everyday life after vision loss.
Re: Integrated Low Vision and Mental Health Treatment Can Reduce or Prevent DepressionPosted by Audrey Demmitt on 7/17/2014 at 7:03 PM
Excellent article Maureen and a very important subject. I have read other studies that report as much as 60% of clients experiencing vision loss will also have depression. It makes sense to approach this "wholistically" and inter-discipinary. I believe if client's can recognize depression and get the help they need, they will accomplish more from the rehabilitation standpoint. Depression can be dibilitating in and of itself.When it is addressed and treated properly, clients can move forward through the adjustment process and will have greater motivation and energy to learn new skills.Thanks for bringing this subject to the forefront. Sometimes peopel need "permission" and knowledge to address it.
Re: Integrated Low Vision and Mental Health Treatment Can Reduce or Prevent DepressionPosted by maribelsteel on 7/18/2014 at 5:33 PM
Maureen, thank you for summerising the article and its findings - I am so pleased that within medical traetments we can address the whole person and not just their medical condition. Its paramount for those of us with fading sight to stay connected to our source and not disengage, after all that is the true definition of 'dis-abled' - but when we stay connected we can enjoy our purpose in life, it's about finding different ways to do the things we love, as they said in their research findings. It does take a certain amount of courage but with support and a well rounded approach like they have trialed, is a great way forward!
Re: Integrated Low Vision and Mental Health Treatment Can Reduce or Prevent DepressionPosted by MaureenD on 7/18/2014 at 5:37 PM
I was very pleased to read this research, too. The same research group has also published a related article in the May-June issue of the Journal of Visual Impairment and Blindness, which examined specific personality traits and functional vision: "Personality and Functional Vision in Older Adults with Age-Related Macular Degeneration" (http://www.afb.org/afbpress/pubjvib.asp?DocID=jvib080303)
In that article, the researchers examined whether personality traits influence self-reported functional vision in people with age-related macular degeneration (AMD) and concluded that self-reported functional vision depends on the severity of vision loss as well as the personality trait of neuroticism.
I am grateful to this research group for their ongoing work in this area. Another aspect of this research that will prove to be helpful is that we are finally "quantifying" the effects of vision rehabilitation services. What that means in this context is that we are getting closer to being able to say with confidence that vision rehabilitation "works" or makes a difference.
It's not enough any more to say that vision rehabilitation helps people or that it is "good." What funders want is "proof" (i.e., a numerical measurement of some kind) that clearly indicates a measurable difference in people's function after participating in vision rehabilitation.
Not to be too geeky about it (It sounds geeky, right?), but measurable change is what we have to start demonstrating in our field if we are to keep progressing.
Re: Integrated Low Vision and Mental Health Treatment Can Reduce or Prevent DepressionPosted by Audrey Demmitt on 7/19/2014 at 6:43 PM
Indeed....I am quite aware of the burden to "quantify" and demonstrate measurable outcomes to validate vision rehabilitation services. There are so many variables to consider and I think personality, attitude, and mental health status is a critical piece that should not be overlooked. It may even be the most important variable to address asearly as possible in the rehab process. I used a depression and anxiety scale to screen my clients as they began their rehab services and it was quite enlightening for them. Often it resulted in getting mental health services concurrently.
As the approach to vision rehab is refined and quantified, we can hope that insurance companies will finally recognize it and reimburse for the service!
Re: Integrated Low Vision and Mental Health Treatment Can Reduce or Prevent DepressionPosted by MaureenD on 7/23/2014 at 7:25 PM
I agree with everything you say and I am impressed that you screened for anxiety and depression as a routine part of the vision rehabilitation process.
I think you might be interested in my friend Kaye Olson, who directed the Coping with Vision Loss Study, which I wrote about here on the VisionAware website.
I think it is a fantastic study that includes the elements you mention. (Plus she is a great lady ...)
I also did a longform interview/personal story with Kaye that is equally wonderful.
And thank you for your supportive comments about this important study. As I said, I admire the authors tremendously for undertaking it.
Re: Integrated Low Vision and Mental Health Treatment Can Reduce or Prevent DepressionPosted by rontjohnson84 on 7/28/2014 at 4:18 PM
Thanks so much for summarizing this study. I am very interested in it as I also am affected by MD. If you are interested in discussing this report on a radio show, I think it could help many people affected by vision loss and depression. I host a radio show in the Dallas area that's broadcast to over 40,000 people affected by vision loss. Please send me an email at firstname.lastname@example.org if you are interested. I would love to have you on the show!
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