In part one of this two-part series on depression and sight loss, I introduced the finding that depression is common in people with a visual impairment. To set this in context, I reviewed the diagnostic criteria for depression, examined the theoretical link between depression and sight loss and discussed depression screening questionnaires. In this follow on article, I will present recent research from Cardiff University investigating treatments for people experiencing sight loss and depression, before discussing the important practical steps that you can take to help this cohort of patients.

Current intervention

In part one we learned studies consistently show depression is common in people experiencing sight loss. Results from a number of studies in the USA over the past 20 years have shown the prevalence of depression and depressive symptoms in those attending visual rehabilitation centres is around 22 to 38%.1-4 In response to this, a small number of studies have examined the effectiveness of potential psychological treatments for depression in this population.5-7

The thought of losing one’s sight can lead to depression

Currently, there are no evidence-based recommendations for the treatments that should be offered. The best guidance we have is the clinical guideline from the National Institute for Health and Care Excellence (NICE) entitled ‘Depression in adults with a chronic physical health problem: recognition and management’.8 The guidelines recommend a stepped-care approach to depression, in which the least intrusive intervention is offered first, and if this is not effective, then the patient can be offered a more intensive treatment. The recommended treatments include psychological therapy such as cognitive behavioural therapy, physical exercise programmes, group peer support and medication, although anti-depressants are not generally recommended for mild depression.

Following on from the work of the research groups in the USA, my colleagues at Cardiff University were keen to establish;

a The prevalence of depression in UK low vision clinics.

b The effectiveness of one of the therapies in the NICE guidelines for this population.

To this end, they established the Depression in Visual Impairment Trial9 (DEPVIT), the first of its kind in the UK.

Aims of DEPVIT

The first aim of the trial was to establish a reliable estimate of the prevalence of depressive symptoms in people attending low vision clinics, both on the high street and in hospital clinics, to determine the extent of the problem in the UK. To achieve this, we screened just over 1,000 attendees in clinics across South Wales and at St Thomas’ Hospital in London. Screening involved sending the Geriatric Depression Scale (GDS-15) to patients prior to their appointment, asking them to complete it and bring it along with them. If they had not completed it, but were willing to do so, they could fill it out in the waiting room. The questionnaire contains 15 items, and a score of six or more is taken to indicate that the person has significant depressive symptoms (but cannot diagnose depression). We were shocked to find that 43% reported significant depression symptoms, a higher figure than in any of the American studies.10 And of these patients, 75% were not receiving any treatment. These findings confirmed to us that depression in this population is a significant problem which needs to be highlighted to optometrists and should be addressed in clinical practice.

The second aim of DEPVIT was to investigate the usefulness of two interventions for people with sight loss and depression compared to doing nothing. The first intervention was simply to refer the person to their GP. We wrote to the GP, explaining that the person had screened positive for depressive symptoms and asked them to assess the person and consider the NICE guidelines. It was then up to the GP whether they saw the patient, and what treatment, if any, they offered. The second intervention we considered was problem solving therapy (PST). PST is a form of cognitive behavioural therapy and is recommended in the NICE guidelines for people with depression and a chronic illness. We chose PST because a previous study in America had shown that in people with age-related macular degeneration (AMD), it was effective at preventing depression.11 In PST, patients work with a therapist to learn a seven step method for approaching and solving their problems. We delivered PST in the patient’s own home over approximately six sessions. Patients were able to work on any vision or non-vision-related problems they identified were causing them distress.

Outcome

In total, 85 participants with sight loss and depression from across South Wales and London took part in the trial. We assessed their depressive symptoms at the start, after three months and after six months. Thirty-one were allocated a referral to their GP, 24 were allocated to PST and 30 were allocated no treatment (the control condition). We found that at six months, depressive symptoms had reduced in all three groups.12 Those in the PST condition experienced the greatest reduction in depressive symptoms, followed by those referred to the GP, then those who received nothing. However, the changes in all three groups were small and the findings suggest that neither intervention would make an important clinical difference to depression. So why were the interventions not more helpful?

Actually, PST proved to be a life changing intervention for some. For example, I can remember the story of one man, let us call him Alan, who had not left the house on his own for 10 years following a fall while in town. He bitterly missed his independence and that was contributing to his depression. With his therapist, he brainstormed ways to regain the independence, including how to communicate to his worried wife that he wanted to go alone, practical ways to manage the journey and addressing his worries about another fall. By the end of the therapy, Alan was making a weekly trip into town on his own, going to the library to hire the audio books he had so missed. His mood changed completely and he was a PST success story.

But sadly for many others, PST was not so helpful. For people with co-morbid conditions such as arthritis, diabetes and multiple sclerosis, fluctuations in their physical health took priority over their mood and weekly sessions were hard to stick to due to being in pain or having to make hospital visits. For others, the fear of sight loss was so distressing, that they simply wanted to share their emotions rather than focus on a fairly practical therapy. And for those still in denial about their low mood, they did not believe that they had any problems to work on.

We were able to learn what happened to 32 of the 36 patients referred to the GP. Twenty-five per cent were offered anti-depressants and these patients, on average, made the biggest improvements of anyone in the trial; enough to be considered clinically significant. On the downside, a third of participants did not even receive a consultation, either because the GP did not receive our referral letter, did not offer a consultation, or the patient did not attend, leaving this group without any treatment.

Eye care practitioners

We know from previous research that people with sight loss are the group least likely to have their depression recognised by a their GP.13 Therefore, following our research, we believe eye care practitioners have a responsibility of care to their patients to consider their mental health. The NICE guidelines also recommend that health professionals working with patients with a chronic physical health problem associated with a functional impairment should be alert to, and screen for, possible depression. So what do you need to do?

I suggest the following steps;

Step 1: Screening

As the prevalence of depressive symptoms is so high, we recommend screening all patients with a visual impairment. There are a couple of ways that you can do this. The first option is to use a screening questionnaire, as we did in the DEPVIT trial. We recommend the Patient Health Questionnaire14 (PHQ-9), a screening tool used widely in primary care and familiar to most GPs. The patient indicates how often they have experienced nine symptoms of depression in the past two weeks. You could send the questionnaire to the patient with the appointment letter, asking them to complete it prior to their appointment and to bring it with them on the day. Alternatively, you could ask them to complete it in the waiting room, but it is important to consider that the person may need help to complete it depending on their level of visual impairment, so confidentiality may be an issue. We recommend providing it in large print. Scores of five, 10, and 15 represent cut off points for mild, moderate, and severe levels of depressive symptoms. A cut off point of 10 or greater is considered a yellow flag, indicating a possible clinically significant condition. You can obtain a copy of the questionnaire and instructions on scoring it from the web address listed at the end of this article.

Understandably, some of the optometrists in the DEPVIT trial had concerns about sending out a depression questionnaire to patients attending an eye appointment, as it is likely to be unexpected. However, we found a high percentage completed the questionnaire, and as we have seen, for nearly half of them the questionnaire would have been relevant and perhaps welcome.

An alternative method may be preferable for those of you wishing to incorporate the screening into the clinical assessment. The NICE guidelines on depression recommend that non-mental health professionals ask patients who may have depression two questions:

  • During the last month, have you been bothered by feeling down, depressed or hopeless?
  • During the last month, have you been bothered by having little interest or pleasure in doing things?

If the answer to either of these is ‘yes’, the person may be experiencing depression.15 These questions can be asked as part of the information gathering on general health, and therefore you may feel they fit more naturally into the appointment than a separate questionnaire.

The optometrists’ main concerns were that patients might find depression screening intrusive or inappropriate. Our colleagues in Australia were keen to understand whether this might be the case and conducted a study to answer the question.16 They screened 124 older adults accessing low vision rehabilitation services and eye care clinics using the PHQ-2 – see table 1. The PHQ-2 is a brief screen using the first two items from the PHQ-9; they are the same questions as recommended by the NICE guidelines, but are scored on frequency, rather than as ‘yes/no’. A score of three or more is indicative of depressive symptoms. Following the screening, the participants were asked about the acceptability of being screened.

Table 1: PHQ-2

The researchers found that 85% of patients thought that it was a ‘good idea’ to screen for depression in low vision services and most (86%) rated the questions on the PHQ-2 as ‘easy’ or ‘very easy’ to answer. Nearly all said they did not feel embarrassed (96%), upset (96%) or uncomfortable (96%) answering the questions. There was no difference in the level of acceptance towards screening in those who screened positive for depression to those who screened negative.

Given that we know the prevalence of depression is high; patients find screening to be acceptable; and there are quick and easy screens available, there seems little reason not to screen this population for depression.

Step 2: Feedback to the patient and normalise

Once you have screened the patient, either with the questionnaire or as part of your assessment, the next step is to provide them with feedback. If they score less than five on the PHQ-9, or answer ‘no’ to both of the NICE questions, then it is unlikely they have significant depressive symptoms. You can feedback to the patient that they seem to be adapting well to their sight loss and that there seems to be no significant effect on their mood. It is also a good idea to check that they agree this is the case, and then no further action is required at this appointment.

Where appropriate, anti-depressants can prove effective

A score of 10 or more on the PHQ-9 or a ‘yes’ response to either or the two NICE questions would suggest that the person is experiencing significant depressive symptoms. It is important to feedback this back to the patient, using language they have used/might use themselves. For example, you could let them know that their responses on the questionnaire/to your questions indicate that they are not feeling themselves at the moment, or that they seem to being feeling down or low. You can pick out some of their responses to introduce the conversation. ‘Depression’ can be a highly emotive word and it is sometimes helpful to use alternatives, however, do not play their symptoms down. It is important to note that the low mood may or may not be due to the sight loss – do not assume it is so. You can check with them that the questionnaire is a good representation of how they are feeling and discuss whether the sight loss is playing a part in their mood.

Once you have fed back the score, and what it may mean, it is important to normalise what the person is experiencing and give hope. You may remember Ted from my first article. He came to me feeling tired, demotivated and down, and wondered if I had ever heard of anything like it. It helped Ted to know that many people experienced similar symptoms and that he was certainly not alone. At this point you could let the patient know that low mood is common, especially in people experiencing sight loss, hence why we ask about it. Explain that while depression is not inevitable, many people do have difficulties adjusting to sight loss (or other reasons they have given for their mood) and that they are not alone. You can give hope by letting them know that there are effective treatments for depression which can be accessed via the GP and that you will make a referral. Plus, support is available through the sight loss charities.

Genuine emotional support can help

If the patient has scored five to nine on the PHQ-9, this indicates the possibility of mild depression. In this case, I recommend feeding back to the patient that they have one or two symptoms of low mood and check how they are coping. Suggest that they (and you) keep an eye on this and that they should make an appointment with their GP if they begin to feel worse.

Step 3: Refer to GP/Signpost

Currently, treatments for depression are usually accessed through the GP who can either prescribe anti-depressants, or refer a person for a psychological intervention (talking therapy) in primary care. Therefore, for people scoring 10 or more on the PHQ-9 or answering ‘yes’ to either of the NICE questions, explain that you will be asking their GP to assess them unless they strongly do not wish to be referred.

I recommend writing to the patient’s GP explaining that they have scored x on the PHQ-9 or answered the screening questions positively and you would like them to be assessed. It is worth noting that in DEPVIT, not all of our referral letters reached the GP. Therefore, it is important to check that you have the correct GP on record and that their contact details (and the patient’s) are correct. I would highly recommend following up the referral after one week with a telephone call to check that the referral has been received and acknowledged, and we would certainly do this if running another study.

As mentioned above, those referred to the GP in DEPVIT did better than those who had no treatment and while this was not clinically significant for all, the gains were better for those with moderate to severe depression and those who were prescribed anti-depressants. Our colleagues in Australia also found that for patients who went to the GP, depressive symptoms decreased significantly over six months, whereas this did not happen for people who did not go their GP.17 Importantly, they found that only 46% of people referred to their GP went, suggesting that it is also important to encourage the patient to make an appointment with their GP if their GP does not get in touch with them.

As an additional measure, or instead of the GP if the patient really will not be referred, you can signpost the patient to local support groups/voluntary sector services in you area. The Macular Society, RNIB and Guide Dogs all have services such as telephone befriending, support group meetings and guides to help build confidence in getting about. Get to know what is in your area and keep a large print list to hand out.

The future of sight loss and depression

In terms of clinical practice, the DEPVIT team really believe addressing depression should be part of the low vision optometrist’s role. It should make visual rehabilitation easier. As I explained in the previous article, it is almost hopeless for example, to give visual aids to someone who has yet to acknowledge their sight loss and is battling on in denial. I commonly hear from optometrists about the frustrations of giving out potentially useful technologies which are stuffed in a drawer or the patient refuses to use. Perhaps by addressing the emotional response first, the patient can be given the help they need to come to terms with their loss and can develop the motivation needed to use such devices and in doing so minimise the impact on their functioning.

In terms of research, the future sadly does not look bright. Following the DEPVIT outcomes, we organised an international meeting of experts in the field of low vision and depression, researchers in psychological treatments, patients with sight loss and the voluntary sector, to determine the next step. Based on that meeting and the outcomes of our colleagues in the Netherlands7 we agreed that the best intervention would follow a stepped-care model similar to the one recommended by NICE. Together we drafted a proposal seeking grant funding to test this model in the UK, but neither the government nor the charity sector in the UK saw it as a priority area and we have been unable to secure funding for further research. Our colleagues in Australia and the Netherlands continue to work in this area, and we sincerely hope they can provide more answers.

If you have any questions or comments about this article, please do not hesitate to get in touch, I would be happy to hear from you: nollettcl@cardiff.ac.uk.

Claire Nollett is research associate/trial manager, Centre for Trials Research, Cardiff University.

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