Rehabilitation or referral of depressed low vision patients

Press/Media: Expert Comment


Editorial e-learning low vision service USA

Period1 Jan 2010

Media contributions


Media contributions

  • TitlePPLVR
    Degree of recognitionInternational
    Media name/outletPrinciples & Practice of Low Vision Rehabilitation (PPLVR) website
    Media typeWeb
    Country/TerritoryUnited States
    DescriptionDemographic aging will lead to an increased demand for medical care, including low visionrehabilitation. Therefore, in the near future, low vision rehabilitation centers need to make efficientdecisions and choose the rehabilitation program that has the greatest likelihood of benefiting eachindividual. The growing demand for service by our aging population probably means that low visioncenters will no longer be able to afford spending too much time on any one patient without being surethe patient is going to benefit from the offered treatment.We know from a number of studies that even early signs of depression can interfere with rehabilitationoutcomes in low vision patients. Reduced scores on vision related quality of life measures fordepressed elderly have been reported,1 which means that the effect of low vision rehabilitation wasunsatisfactory for these patients. There may be different ways that depression interferes with lowvision rehabilitation outcomes (e.g. reading aids training, mobility training or training in activities ofdaily life). Depression can affect a person’s learning capacity or ability to retain information, and it alsocould result in a disturbance in thought processes, difficulty in making decisions, or difficulty orientingtowards achieving goals.2 Consequently, some depressed visually impaired persons do not benefitfrom low vision rehabilitation. Recognizing depression and making referrals to either mental healthcare or specialized low vision rehabilitation programs is necessary to improve low vision rehabilitationoutcomes for those patients. In the Principles & Practice of Low Vision Rehabilitation (PPLVR) courseon “Depression and Psychological Adjustment in Low Vision”, there are some important suggestionsmade by Dr. Julia Kleinschmidt and Dr. Barry Rovner, which can be considered guidelines on how tohandle individual visually impaired patients who are suffering from depression.Grief is perfectly normal. Kleinschmidt is very clear about expectations for patients who just lost mostor part of their vision or who were recently diagnosed with an irreversible progressive eye disorder.She argues that it is normal for a patient to go through a period of grief — a person who recently lostvision should be grieving. This is important guidance, because as a low vision clinician, a visionrehabilitation worker, a psychologist, a social worker, occupational therapist, or other specialistproviding low vision rehabilitation service we might be inclined to jump to conclusions and immediatelystart giving people advice on how they should react and how they will eventually cope with theirproblem, that they will find out that life is worth living, even with vision loss. Indeed, we have seen fromour “successful” patients that they will progress and that eventually they will be fine once they knowbetter how to handle being visually impaired. Kleinschmidt advises us to first step back and tell ourpatients that there is nothing wrong with grief. We need to be empathetic and supportive while thepatient experiences this initial stage of coping.But what if a person does not come out of a period of grief? Rovner states that about one third ofvisually impaired persons keep on being depressed even eight weeks after the diagnosis of an eyedisease, or loss of vision. In that case the depression can probably be considered a serious medicalcondition that is not simply a normal reaction to vision loss. A clinically diagnosed depression can beconsidered a major threat to quality of life, to the ability to cope with daily life activities and even to lifeexpectancy. In the geriatric literature it is well known that depression often accompanies disablingdiseases, that depression aggravates existing disability, and that functioning can improve once it istreated adequately.3Fortunately, not all elderly patients with vision loss suffer from depression. It has been suggested thatvisually impaired elderly with progressive visual acuity loss, poor health, co-morbidity and less selfefficacy,4-9 are more prone to develop depressive symptoms than their counterparts. Therefore, thefinding of Rovner that it is perfectly normal after diagnosis or vision loss to be depressed, sad oroverwhelmed for approximately eight weeks, could be taken as a guideline as well.Intervention options. Both Kleinschmidt and Rovner suggest to start intervention if it takes too long fora person to come out of the depressive episode. At this point we have to make another decision in ourcare process for the depressed visually impaired person. Which intervention should we start first? Wecould start with giving our patients low vision aids, mobility training, occupational therapy, cookingclasses, or all regular low vision rehabilitation which one would usually provide to a visually impairedpatient. Rovner calls low vision rehabilitation programs a form of psychotherapy, similar to problemsolving therapy. There also could be indirect effects of low vision rehabilitation on depression. Forexample, walking is proven to be an effective therapy for depression in general populations, so once aperson is able to go out again because of mobility training, it should at least partly ameliorate thedepression. I do think, however, this ‘indirect psychotherapy’ is different from directly addressing themental problem, which happens in psychotherapy sessions with a psychologist or psychiatrist, whichoftentimes includes giving our patients antidepressants.Which option to choose will probably depend on a more thorough study of our patient. In the past,Leinhaas and Hedstrom (1994) have described a model of low vision services that involvedassessment of all patients by social workers for depressive symptoms. Those who met diagnosticcriteria were referred to psychiatric consultation and the low vision intervention was delayed pendingtreatment for depression.10 To delay all interventions does not seem appropriate, such as prescriptionof low vision aids or adaptations in the home environment, but a delay could be appropriate for morecomprehensive low vision rehabilitation programs that require much effort of the patient, suchas orientation and mobility training, activities of daily living training (ADL's), or specific training for theuse of various reading aids (e.g. working with a CCTV). In contrast, but similar to what Rovnersuggests, Dodds (1991) described a model in which skill training in itself would produce animprovement in the client’s self-perception by letting him see his own competence increasing.11The suggested problem solving therapy (PST) is a very attractive one, because first, with PST it ispossible to combine low vision rehabilitation and psychotherapy by teaching patients techniques onhow to solve their own problems. Moreover, it will give visually impaired patients more self-esteemonce they have actually experienced that it is possible to be independent up to a certain level. Second,PST may be given by social workers or psychologists in a therapy session, but it can be integrated in arehabilitation worker’s every day practice as well.Taking the severity of depression into account. Despite the best efforts of the rehabilitation specialist,improvement may still depend on the severity of the depression and the factors that underlie thedepression. That is why I think it is important to know that different medical decisions should be madewhen the depression is merely a reaction to vision loss compared to when, for example, the patienthas a history of depressive episodes. Moreover, we want to know what the severity is of the currentdepressive episode in the individual patient.12,13 Is it a major depression, according to DSM-IV criteria,a minor depression, sub-threshold, dysthymia, seasonal? Recognition of depressive symptoms inolder persons can be complicated. Recently, it was found that in my country (the Netherlands) generalpractitioners failed to diagnose two out of three patients who suffered from depression.14Often the focus of consultation in older persons is directed towards physical complaints and not somuch towards psychological symptoms. This is something Rovner mentions as well in the PPLVRcourse.It is not the fault of the doctor per se, but also patients more easily address physical problemsthan mental problems. One can imagine it to be easier for a patient to describe a painful joint than apainful psychological concept. Similarly, low vision rehabilitation centers may fail to detect depressionand a patient may fail to mention it because of the focus on vision problems. Consequently, patientsare not referred adequately. At the end of Rovner’s lecture he gives us two screening instruments“Geriatric Depression Scale” and the “Patient-Health-Questionnaire-9”. Although we should be awarethat these screeners are not going to answer the question whether the patient is suffering from a majordepression according to DSM-IV criteria, they will point us in the direction of a referral inside or outsidethe low vision rehabilitation center.We should also be aware that depression in older age may manifest itself differently from that seen inyounger people. Another guideline Rovner gives us, is a list of medical and psychosocial variablesthat are risk factors for depression (e.g. female gender, medical illness, physical disability, economichardship, etc.). A combination of a screening tool and these easy-to-determine patient characteristicsmight be essential to filter out persons who will initially not benefit as much from rehabilitation. It mayalert us and it will make us see that this individual patient needs to be further evaluated so we canoffer adequate treatment.In conclusion, it may still be difficult to know when to refer depressed visually impaired adults inside oroutside the low vision rehabilitation center, especially if the depression is not simply a consequenceof the vision loss. Using the information from the PPLVR-course on depression as guidelines could help us in making these decisions. Then, rehabilitation is expected to be more effective for visuallyimpaired patients suffering from an extra burden, called depression.References1. Owsley C, McGwin G, Jr. Depression and the 25-item National Eye Institute Visual FunctionQuestionnaire in older adults. Ophthalmology 2004;111:2259-64.2. O'Donnell C. The Greatest Generation Meets Its Greatest Challenge: Vision Loss and Depression inOlder Adults. Journal of Visual Impairment & Blindness 2005;99:197-208.3. Casten RJ, Rovner B, Tasman W. Age-related macular degeneration and depression: a review of recentresearch. Curr Opin Ophthalmol 2004;15:181-3.4. Augustin A, Sahel J, Bandello F, et al. Anxiety and depression prevalence rates in age-related maculardegeneration. Invest Ophthalmol Vis Sci 2007;48:1498-503.5. Brody BL, Gamst AC, Williams RA, et al. Depression, visual acuity, comorbidity, and disability associatedwith age-related macular degeneration. Ophthalmology 2001;108:1893-900.6. Horowitz A, Reinhardt JP, Boerner K, Travis LA. The influence of health, social support quality andrehabilitation on depression among disabled elders. Aging & Mental Health 2003;7:342-50.7. Chou KL, Chi I. Combined effect of vision and hearing impairment on depression in elderly Chinese.International Journal of Geriatric Psychiatry 2004;19:825-32.8. Capella-McDonnall ME. The effects of single and dual sensory loss on symptoms of depression in theelderly. International Journal of Geriatric Psychiatry 2005;20:855-61.9. Brody BL, Roch-Levecq AC, Kaplan RM, et al. Age-Related Macular Degeneration: Self-Managementand Reduction of Depressive Symptoms in a Randomized, Controlled Study. Journal of the AmericanGeriatrics Society 2006;54:1557-62.10. Leinhaas MA, Hedstrom NJ. Low vision: how to assess and treat its emotional impact. Geriatrics1994;49:53-6.11. Dodds AG. The psychology of rehabilitation. Br J Visual Impairment 1991;9:38-40.12. Beekman ATF, Deeg D, Smit HC, et al. Dysthymia in later life: a study in the community. J Affect Disord2004;81:191-9.13. de Beurs E, Comijs HC, Twisk JWR, et al. Stability and change of emotional functioning in late life:modelling of vulnerability profiles. J Affect Disord 2005;84:53-62.14. Licht-Strunk E, Beekman ATF, de Haan M, van Marwijk HWJ. The prognosis of undetected depressionin older general practice patients. A one-year follow-up study. J Affect Disord, in press 2007.
    Producer/AuthorRW Massof
    PersonsRuth van Nispen