Integrated depression management: a proposed trial of a new model of care in a low vision rehabilitation setting

Correlation between global prevalence of vision impairment and depressive disorders

PURPOSE

To assess the correlation of the worldwide prevalence of visual impairment and depressive disorders.

METHODS

This is an ecologic study on Global Burden of Disease 2019 data. Global and national prevalence numbers and rates of vision impairment (VI) and depressive disorders were obtained from database. The human development index (HDI) and socio-demographic index (SDI) were derived from international open databases. Main outcome measures were the correlation of the VI and depressive disorders in total and different age, sex, and socioeconomic subgroups.

RESULTS

In 2019, the worldwide prevalence of total VI and total depressive disorders were 9.6% (95% Uncertainty Interval (UI): 8.0-11.3) and 3.8% (95% UI: 3.4-4.2), respectively. The prevalence rates of total VI (r = 0.38, P < 0.001) as well as cataract (r = 0.43, P < 0.001), age-related macular degeneration (AMD) (r = 0.32, P < 0.001), refractive disorders (r = 0.19, P < 0.001) and near vision loss (r = 0.33, P < 0.001) correlated, positively, with dysthymia. In addition, the prevalence rates of glaucoma (r for total depressive disorders = 0.37, P < 0.001 and r for major depressive disorders (MDD) = 0.38, P < 0.001) and AMD (r for total depressive disorders = 0.37, P < 0.001 and r for MDD = 0.28, P < 0.001) had a positive correlation with MDD and total depressive disorders. The correlations remained significant in sociodemographic subgroups.

CONCLUSION

There was a significant correlation between national prevalence rates of VI and ocular disabilities with depressive disorders, worldwide.

Psychological changes among working-age adults with acquired vision impairment: The need for psychological intervention?

This study investigates the psychological impacts of acquiring a vision impairment during working-age phase of adulthood and the potential negative effect on participation in community activities were highlighted. Adopting a qualitative and interpretive phenomenological approach, eight semi-structured in-depth interviews were conducted with eight adult users of vision rehabilitation services. Three broad themes were identified: (1) reduced participation in education, employment, and community activities, (2) feelings of hopelessness and depression from vision loss, and (3) psychological adjustment to vision loss over time. Findings are discussed in the context of the international literature, and recommendations that may enhance the vision rehabilitation services are made.

The Michigan Vision-Related Anxiety Questionnaire: A Psychosocial Outcomes Measure for Inherited Retinal Degenerations

OBJECTIVE

We sought to construct and validate a patient-reported outcome measure for screening and monitoring vision-related anxiety in patients with inherited retinal degenerations.

DESIGN

Item-response theory and graded response modeling to quantitatively validate questionnaire items generated from qualitative interviews and patient feedback.

METHODS

Patients at the Kellogg Eye Center (University of Michigan, Ann Arbor, Michigan, USA) with a clinical diagnosis of an inherited retinal degeneration (n = 128) participated in an interviewer-administered questionnaire. The questionnaire consisted of 166 items, 26 of which pertained to concepts of "worry" and "anxiety." The subset of vision-related anxiety questions was analyzed by a graded response model using the Cai Metropolis-Hastings Robbins-Monro algorithm in the R software mirt package. Item reduction was performed based on item fit, item information, and item discriminability. To assess test-retest variability, 25 participants completed the questionnaire a second time 4 to 16 days later.

RESULTS

The final questionnaire consisted of 14 items divided into 2 unidimensional domains: rod function anxiety and cone function anxiety. The questionnaire exhibited convergent validity with the Patient Health Questionnaire for symptoms of depression and anxiety. This vision-related anxiety questionnaire has high marginal reliability (0.81 for rod-function anxiety, 0.83 for cone-function anxiety) and exhibits minimal test-retest variability (ρ = 0.81 [0.64-0.91] for rod-function anxiety and ρ = 0.83 [0.68-0.92] for cone-function anxiety).

CONCLUSIONS

The Michigan Vision-Related Anxiety Questionnaire is a psychometrically validated 14-item patient-reported outcome measure to be used as a psychosocial screening and monitoring tool for patients with inherited retinal degenerations. It can be used in therapeutic clinical trials for measuring the benefit of an investigational therapy on a patient's vision-related anxiety.

Low vision rehabilitation for better quality of life in visually impaired adults

BACKGROUND

Low vision rehabilitation aims to optimise the use of residual vision after severe vision loss, but also aims to teach skills in order to improve visual functioning in daily life. Other aims include helping people to adapt to permanent vision loss and improving psychosocial functioning. These skills promote independence and active participation in society. Low vision rehabilitation should ultimately improve quality of life (QOL) for people who have visual impairment.

OBJECTIVES

To assess the effectiveness of low vision rehabilitation interventions on health-related QOL (HRQOL), vision-related QOL (VRQOL) or visual functioning and other closely related patient-reported outcomes in visually impaired adults.

SEARCH METHODS

We searched relevant electronic databases and trials registers up to 18 September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating HRQOL, VRQOL and related outcomes of adults, with an irreversible visual impairment (World Health Organization criteria). We included studies that compared rehabilitation interventions with active or inactive control.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 44 studies (73 reports) conducted in North America, Australia, Europe and Asia. Considering the clinical diversity of low vision rehabilitation interventions, the studies were categorised into four groups of related intervention types (and by comparator): (1) psychological therapies and/or group programmes, (2) methods of enhancing vision, (3) multidisciplinary rehabilitation programmes, (4) other programmes. Comparators were no care or waiting list as an inactive control group, usual care or other active control group. Participants included in the reported studies were mainly older adults with visual impairment or blindness, often as a result of age-related macular degeneration (AMD). Study settings were often hospitals or low vision rehabilitation services. Effects were measured at the short-term (six months or less) in most studies. Not all studies reported on funding, but those who did were supported by public or non-profit funders (N = 31), except for two studies. Compared to inactive comparators, we found very low-certainty evidence of no beneficial effects on HRQOL that was imprecisely estimated for psychological therapies and/or group programmes (SMD 0.26, 95% CI -0.28 to 0.80; participants = 183; studies = 1) and an imprecise estimate suggesting little or no effect of multidisciplinary rehabilitation programmes (SMD -0.08, 95% CI -0.37 to 0.21; participants = 183; studies = 2; I2 = 0%); no data were available for methods of enhancing vision or other programmes. Regarding VRQOL, we found low- or very low-certainty evidence of imprecisely estimated benefit with psychological therapies and/or group programmes (SMD -0.23, 95% CI -0.53 to 0.08; studies = 2; I2 = 24%) and methods of enhancing vision (SMD -0.19, 95% CI -0.54 to 0.15; participants = 262; studies = 5; I2 = 34%). Two studies using multidisciplinary rehabilitation programmes showed beneficial but inconsistent results, of which one study, which was at low risk of bias and used intensive rehabilitation, recorded a very large and significant effect (SMD: -1.64, 95% CI -2.05 to -1.24), and the other a small and uncertain effect (SMD -0.42, 95%: -0.90 to 0.07). Compared to active comparators, we found very low-certainty evidence of small or no beneficial effects on HRQOL that were imprecisely estimated with psychological therapies and/or group programmes including no difference (SMD -0.09, 95% CI -0.39 to 0.20; participants = 600; studies = 4; I2 = 67%). We also found very low-certainty evidence of small or no beneficial effects with methods of enhancing vision, that were imprecisely estimated (SMD -0.09, 95% CI -0.28 to 0.09; participants = 443; studies = 2; I2 = 0%) and multidisciplinary rehabilitation programmes (SMD -0.10, 95% CI -0.31 to 0.12; participants = 375; studies = 2; I2 = 0%). Concerning VRQOL, low-certainty evidence of small or no beneficial effects that were imprecisely estimated, was found with psychological therapies and/or group programmes (SMD -0.11, 95% CI -0.24 to 0.01; participants = 1245; studies = 7; I2 = 19%) and moderate-certainty evidence of small effects with methods of enhancing vision (SMD -0.24, 95% CI -0.40 to -0.08; participants = 660; studies = 7; I2 = 16%). No additional benefit was found with multidisciplinary rehabilitation programmes (SMD 0.01, 95% CI -0.18 to 0.20; participants = 464; studies = 3; I2 = 0%; low-certainty evidence). Among secondary outcomes, very low-certainty evidence of a significant and large, but imprecisely estimated benefit on self-efficacy or self-esteem was found for psychological therapies and/or group programmes versus waiting list or no care (SMD -0.85, 95% CI -1.48 to -0.22; participants = 456; studies = 5; I2 = 91%). In addition, very low-certainty evidence of a significant and large estimated benefit on depression was found for psychological therapies and/or group programmes versus waiting list or no care (SMD -1.23, 95% CI -2.18 to -0.28; participants = 456; studies = 5; I2 = 94%), and moderate-certainty evidence of a small benefit versus usual care (SMD -0.14, 95% CI -0.25 to -0.04; participants = 1334; studies = 9; I2 = 0%). ln the few studies in which (serious) adverse events were reported, these seemed unrelated to low vision rehabilitation.

AUTHORS' CONCLUSIONS

In this Cochrane Review, no evidence of benefit was found of diverse types of low vision rehabilitation interventions on HRQOL. We found low- and moderate-certainty evidence, respectively, of a small benefit on VRQOL in studies comparing psychological therapies or methods for enhancing vision with active comparators. The type of rehabilitation varied among studies, even within intervention groups, but benefits were detected even if compared to active control groups. Studies were conducted on adults with visual impairment mainly of older age, living in high-income countries and often having AMD. Most of the included studies on low vision rehabilitation had a short follow-up, Despite these limitations, the consistent direction of the effects in this review towards benefit justifies further research activities of better methodological quality including longer maintenance effects and costs of several types of low vision rehabilitation. Research on the working mechanisms of components of rehabilitation interventions in different settings, including low-income countries, is also needed.

Predictors of depression and life satisfaction in visually impaired people

BACKGROUND

Visual impairment can lead loss of functional ability, necessity of accommodations and assistive technologies or having to rely on others for help. This can bring about feelings of sadness, dependency, inadequacy, and fear, which can put a person at risk for depression and affect one's satisfaction with life.

PURPOSE

The aim of this study was to examine the effects of socio-demographic factors, disability-related factors, optimism, pessimism, self-esteem and social support on depression, and life satisfaction in visually impaired people.

METHODS

A total of 94 visually impaired people completed the measures of socio-demographic and disability-related characteristics, optimism and pessimism, self-esteem, social support, depression and life satisfaction, administered by the authors. Correlational and hierarchical regression analysis was used to examine the relations and test the model for predicting depression and life satisfaction.

RESULTS

The results have shown that depression was negatively related to the level of education, optimism, self-liking, self-competence, support from friends, family and coworkers, and positively related to comorbidity and pessimism. Life satisfaction was positively related to education, socio-economic status, optimism, self-liking, self-competence and support from friends, family and coworkers, and negatively to pessimism. Results have further shown that depression levels were predicted by education, comorbidity, optimism and self-liking, and that self-liking mediated the relationship between optimism and depression. Life satisfaction was predicted by optimism, pessimism, self-liking, friends' support, and depression. Further analysis suggested that the path from optimism to life satisfaction goes through self-liking, friends' support, and depression. Pessimism showed indirect effects through self-liking but also had direct effects on life satisfaction.

CONCLUSIONS

Focusing on optimism, pessimism, self-esteem, and social functioning of visually impaired is important in preventing depression and promoting life satisfaction, and should be a part of rehabilitation practices. Implications for Rehabilitation Screening for depression and mental health problems should be a part of rehabilitation process. Changes in the perception of future outcomes should be monitored and addressed throughout rehabilitation process in order to boost realistic optimism and prevent discouragement and hopelessness. Frequent feedback and positive reinforcement about a persons' progress and ability should be given throughout rehabilitation process in order to promote positive view of oneself and prevent self-esteem problems. Visually impaired people should be encouraged to socialise outside of their families and participate in social activities. This can be integrated in rehabilitation process as a part of everyday homework.

Can we address depression in vision rehabilitation settings? Professionals' perspectives on the barriers to integrating problem-solving treatment

PURPOSE

Low vision rehabilitation (LVR) is a pertinent context for integrating early, evidence-based psychological interventions given the high prevalence of untreated depression in adults with vision impairment. This study aims to identify the perceived barriers and facilitators to staff-delivered telephone-based problem-solving treatment for primary care (PST-PC) offered as an integrated component of LVR.

METHODS

Qualitative semi-structured interviews, developed using the theoretical domains framework (TDF) and Consolidated Framework for Implementation Research (CFIR), were conducted with 21 LVR professionals and a clinical psychologist involved in the delivery of PST-PC. Barriers and facilitators at the practitioner, client, intervention, and organizational level were identified with thematic analysis using a "theoretical" approach.

RESULTS

Prominent barriers were a lack of role recognition for PST-PC practitioners (n = 32), unmet client expectation with PST-PC (n = 28), dissatisfaction with telephone delivery (n = 27), and limited organizational awareness of PST-PC (n = 39). Facilitating factors included a recognized need for evidence-based psychological services (n = 28), clients experiencing benefits in early sessions (n = 38), PST-PC promoting practical skills (n = 26), and comprehensive PST-PC training (n = 36).

CONCLUSIONS

PST-PC may provide an accessible early intervention for LVR clients with depressive symptoms. Ongoing practitioner training, clinical support, and screening potential LVR clients for treatment suitability are likely to enhance delivery in this setting. Implications for rehabilitation Depression is highly prevalent in adults engaged in low vision rehabilitation (LVR) programs, yet few receive support. Clinical guidelines recommend integrated models of care be offered within rehabilitation settings as early intervention for mild to moderate levels of depressive symptoms. Integrated telephone-based problem-solving treatment for primary care (PST-PC) delivered by trained LVR practitioners is a practical, skills-based model that has potential to increase access to an early psychological intervention in LVR clients with depressive symptoms. LVR clients are often older in age, have multiple comorbid health conditions and a significant level of functional disability, requiring flexibility in the delivery of PST-PC and specialized staff training, and support in working with older and more complex clients.

Estimating Utility Weights for the Vision Related Quality of Life Index

PURPOSE

The VisQoL instrument was constructed as a vision-specific addition to the AQoL-6D multi-attribute utility instrument. The composite instrument, the AQoL-7D, was assigned utility scores that are the basis for now estimating VisQoL utilities when it is used as a stand-alone instrument. This study aimed to construct mapping functions that allow utility scores to be assigned to the Vision Related Quality of Life (VisQoL) instrument, a stand-alone vision-specific quality-of-life measure.

METHODS

A sample of 164 patients completed the AQoL-7D, which includes the VisQoL. Mapping algorithms between VisQoL and AQoL-7D were then derived using two econometric methods, ordinary least squares estimator and generalized linear model (GLM). Two model specifications were considered with either six VisQoL raw item values or VisQoL overall dimension value as the key independent variables. The predictive performance of each method on each model specification was assessed using the mean absolute error (MAE) and intraclass correlation coefficient (ICC). Both internal and external validation tests (using a second, independent sample of 164 patients) were performed.

RESULTS

The mapping algorithms derived from the GLM had superior properties to the ordinary least squares-based algorithms in both internal and external validation tests. The ICC values ranged from 0.851 to 0.913, and the MAE ranged from 0.043 to 0.052 for two model specifications, based on two econometric methods. However, predicted utilities tend to over-predict/under-predict the lowest/highest observed utility.

CONCLUSIONS

Mapping algorithms predicting AQoL-7D utility based on six VisQoL items or VisQoL dimension value have been developed. The algorithm can be used to estimate quality adjusted life years. This allows the VisQoL to be used in cost utility analyses.

Role of vision loss, functional limitations and the supporting network in depression in a general population

PURPOSE

Although the prevalence of depression in visually impaired older persons is high, the association between vision loss and depression seems to be influenced by factors other than visual impairment. In this study, the role of vision loss, functional limitations and social network characteristics in relation to depressive symptoms was investigated.

METHODS

Cross-sectional data (N = 1237) from the Longitudinal Aging Study Amsterdam were used to investigate the prevalence of depression (Center of Epidemiological Studies-Depression scale) within subgroups with increasing vision loss. In linear regression models, functional limitations and social network characteristics were examined as possible mediators in the association between vision loss and depression. Having a partner was considered to be a potential moderator.

RESULTS

Although a significant linear trend was found in the presence of depressive symptoms with 14% in normally sighted, 23% in mild and 37% in severe vision loss (χ(2)(1) = 14.9; p < 0.001), vision loss was not an independent determinant of depression. Mediators were functional limitations (p < 0.001) and social network size (p = 0.009). No interaction with partner status was found.

CONCLUSION

In the presence of depression, a trend was found with increasing severity of vision loss, indicating the need for more attention in (mental) health care and low-vision rehabilitation. In the general older population, vision loss was not an independent determinant of depression but was mediated by functional limitations and social network size. Rather than receiving actual social support, the idea of having a social network to rely on when needed seemed to be associated with lower levels of depression.

Rehabilitation staff perspectives on training for problem-solving therapy for primary care in a low vision service

Vision rehabilitation staff were trained to deliver problem-solving therapy for primary care (PST-PC) over the telephone to adults with depressive symptoms and low vision. Training was a 2-day workshop, completion of training cases, and assessment of treatment fidelity. Staff perspectives of training and challenges in PST-PC delivery were explored. Telephone-administered semi-structured interviews were conducted pre- and post-workshop and following PST-PC competency. In all, 14 staff (mean age = 47.64 years, SD = 12.68 years, 93% females) achieved competency and 6 withdrew. Results showed an increased understanding of PST-PC from pre- to post-workshop ( Z = −2.71, p = .007) and pre-workshop to post-competency ( Z = −3.09, p = .002). A high level of satisfaction with training was reported. Staff challenges included the clients’ ability to define problems and brainstorm solutions. Training enabled staff to competently deliver PST-PC and may serve as a model for integrating depression care into vision rehabilitation services recommended by international guidelines.

Help seeking among vision-impaired adults referred to their GP for depressive symptoms: patient characteristics and outcomes associated with referral uptake

Adults with vision impairment commonly experience depression; however, depression often remains undetected and therefore untreated in this group. Using a prospective longitudinal design, the aim of this study was to determine the rate of uptake for a referral to a general practitioner (GP), in vision-impaired adults, who were screened for depression in low vision rehabilitation and eye-care settings. Fifty-seven vision-impaired adults (aged ≥18 years) were recruited from low vision rehabilitation centres across Australia and the Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, between June 2010 and May 2012. Participants screened positive for depressive symptoms and were referred to their GP for follow up. Telephone assessments took place at baseline, 3 and 6 months to determine uptake of a GP referral and changes in depressive symptoms over 6 months. Forty-six per cent of participants followed through with the GP referral. A desire for emotional support and stigma towards seeking support from a psychologist were significantly associated with uptake (both P < 0.05). GPs were more likely to recommend anti-depressant medication compared with a psychologist consultation (69% v. 54%) and patients themselves were more likely to take anti-depressant medication (94% v. 14% who saw a psychologist). Depressive symptoms decreased significantly over 6 months for those who followed through with a GP referral (baseline M = 10.04, s.d. = 5.76 v. 6-months M = 6.20, s.d. = 3.38; z = –2.26, P = 0.02) but not for those who did not use the GP referral (z = –1.92, P = 0.55). This method of referral to a GP following depression screening may provide an effective pathway to detect and manage depression in vision-impaired adults.

Longitudinal observation, evaluation and interpretation of coping with mental (emotional) health in low vision rehabilitation using the Dutch ICF Activity Inventory

BACKGROUND

Since there is evidence that mental health aspects (such as depression) may inhibit an optimal rehabilitation outcome, there is growing interest in the psychosocial aspects of vision loss as part of rehabilitation. The purpose of this study is to provide more insight into the construct validity and (longitudinal) interpretation of goals related to 'Coping with mental (emotional) health aspects' which are part of the recently developed 'Dutch ICF Activity Inventory (D-AI). Moreover, the data allowed to provide some insight in the outcome in this domain in relation to rehabilitation programs followed in Dutch Multidisciplinary Rehabilitation Centers at baseline and follow-up.

METHODS

In a cohort of 241 visually impaired persons, the D-AI was assessed at baseline (enrollment), 4 and 12 months, The importance and difficulty of the D-AI goals 'Handle feelings', 'Acceptance', and 'Feeling fit' and difficulty scores of underlying tasks were further analyzed, together with similar or related standardized questionnaires. At baseline, Spearman correlations were determined between D-AI goals and task and additional questionnaires to investigate the construct validity. Corrected and uncorrected linear mixed models were used to determine longitudinal rehabilitation outcomes in relation to rehabilitation programs followed.

RESULTS

Baseline correlations indicated that the difficulty of tasks and the umbrella goal 'Acceptance' were not similar. Longitudinal analyses provided insight in some subtle differences in concepts measured at the goal and task level of the D-AI, as well as similar validated questionnaires. After correcting for confounding variables, none of the underlying task difficulty scales changed over time. For goal difficulty scores only 'Acceptance' was reported to be significantly less difficult at 4 and 12 months follow-up. Importance scores of goals were stable from baseline to follow-up.

CONCLUSION

With respect to the constructs measured, results support the formulation of the new goal question 'Emotional life' which replaces the goals 'Handle feelings' and 'Acceptance'. Results indicate that MRCs should pay more attention to problems related to mental health. They have started to use the D-AI as it seems a promising tool to investigate and evaluate rehabilitation needs (including those related to mental health) over time and to clearly define rehabilitation goals from the very start.

Visual impairment is associated with physical and mental comorbidities in older adults: a cross-sectional study

BACKGROUND

Visual impairment is common in older people and the presence of additional health conditions can compromise health and rehabilitation outcomes. A small number of studies have suggested that comorbities are common in visual impairment; however, those studies have relied on self-report and have assessed a relatively limited number of comorbid conditions.

METHODS

We conducted a cross-sectional analysis of a dataset of 291,169 registered patients (65-years-old and over) within 314 primary care practices in Scotland, UK. Visual impairment was identified using Read Code ever recorded for blindness and/or low vision (within electronic medical records). Prevalence, odds ratios (from prevalence rates standardised by stratifying individuals by age groups (65 to 69 years; 70 to 74; 75 to 79; 80 to 84; and 85 and over), gender and deprivation quintiles) and 95% confidence intervals (95% CI) of 37 individual chronic physical/mental health conditions and total number of conditions were calculated and compared for those with visual impairment to those without.

RESULTS

Twenty seven of the 29 physical health conditions and all eight mental health conditions were significantly more likely to be recorded for individuals with visual impairment compared to individuals without visual impairment, after standardising for age, gender and social deprivation. Individuals with visual impairment were also significantly more likely to have more comorbidities (for example, five or more conditions (odds ratio (OR) 2.05 95% CI 1.94 to 2.18)).

CONCLUSIONS

Patients aged 65 years and older with visual impairment have a broad range of physical and mental health comorbidities compared to those of the same age without visual impairment, and are more likely to have multiple comorbidities. This has important implications for clinical practice and for the future design of integrated services to meet the complex needs of patients with visual impairment, for example, embedding depression and hearing screening within eye care services.

Depression screening among older adults attending low-vision rehabilitation and eye-care services: Characteristics of those who screen positive and client acceptability of screening

AIM

To investigate characteristics associated with screening positive for depressive symptoms among older adults accessing low-vision rehabilitation and eye-care services and to determine client acceptability of depression screening using the Patient Health Questionnaire-2 (PHQ-2) in these settings.

METHODS

One-hundred and twenty-four older adults (mean = 77.02 years, SD = 9.12) attending low-vision rehabilitation and eye-care services across Australia were screened for depression and invited to complete a telephone-administered questionnaire to determine characteristics associated with depressive symptoms and client acceptability of screening in these settings.

RESULTS

Thirty-seven per cent (n = 46/124) of participants screened positive for depressive symptoms, and the majority considered the new depression screening method to be a 'good idea' in vision services (85%). Severe vision loss (<6/60 in the better eye) was associated with an increased odds of screening positive for depressive symptoms (odds ratio 2.37; 95% confidence interval 1.08-6.70) even after adjusting for potential confounders. Participants who screened positive had a preference for 'talking' therapy or a combination of medication and 'talking therapy' delivered within their own home (73%) or via telephone (67%).

CONCLUSION

The PHQ-2 appears to be an acceptable method for depression screening in eye-care settings among older adults. Targeted interventions that incorporate home-based or telephone delivered therapy sessions may improve outcomes for depression in this group.