Therapy Helps Avert Depression When Vision Loss Imminent

Not surprisingly, when a person with age-related macular degeneration has already lost vision in one eye and starts to lose it in the other as well, he or she is at high risk for depression. However, a new therapy can prevent depression in such individuals, at least over the short term.

So reported Barry Rovner, M.D., a professor of psychiatry at Jefferson Hospital for Neuroscience in Philadelphia, and colleagues in the August Archives of General Psychiatry.

The new therapy is called problem-solving treatment (PST). The goal is to teach persons with age-related macular degeneration how to compensate for their poor vision and thereby make it possible for them to continue pursuing activities that are important to them.

Rovner and his colleagues explored the possible value of PST in preventing depression in 206 persons who had already lost vision in one eye due to age-related macular degeneration and who had recently been found to have the condition in their other eye as well. None of the subjects was depressed at the start of the study. Half the subjects were randomly assigned to usual care and the other half to PST.

Those assigned to PST received six therapy sessions over an eight-week period in their homes. During these sessions, they were asked to carefully define their visual challenges, to break them down into smaller, more manageable parts, and to brainstorm possible solutions. Solutions might be getting better lighting, reading large-print books, listening to books on tape, using magnifiers, using brightly colored tape to mark stove settings, enlisting the help of others, or being evaluated by a low-vision rehabilitation specialist. They were urged to pursue one or more of these solutions.

From the start of the study to six months later, Rovner and his colleagues followed subjects in both groups to determine whether any became depressed.

At the two-month follow-up, only 12 percent of the PST group had developed depression, compared with 23 percent of the control group—a significant difference. Moreover, the reason why the PST group had a lower level of depression appeared to be because PST helped them to stay engaged in life despite visual impairment.

This positive effect, however, was no longer evident at the six-month follow-up. Although Rovner and his colleagues were disappointed by this result, they were still heartened by the two-month finding. Furthermore, they believe that if booster PST sessions had been offered to PST subjects after the active-treatment phase, it might well have warded off depression for a longer period. “We are in the process of designing a study that will include booster sessions,” Rovner told Psychiatric News.

Meanwhile, if persons with age-related macular degeneration want PST treatment, how can they get it? “Because mental health and eye care are not integrated, it is necessary to go through a mental health provider directly,” Rovner said. “Most older people will not do that. A very reasonable alternative is to see a low-vision ophthalmologist or optometrist, some of whom work with occupational therapists. They can improve function using some of the strategies of PST and thereby possibly prevent depression. We're now preparing an intervention that would train occupational therapists, working with optometrists, to use PST to structure their interventions and directly deal with depressive symptoms.”

Because it is relatively generic, PST could also be applied to prevent depression in individuals with other kinds of medical illnesses, Rovner and his colleagues suggested. In fact, one of them—Mark Hegel, Ph.D., of Dartmouth Medical Center—is using PST to try to prevent depression in women with breast cancer.

In an accompanying editorial, Charles Reynolds III, M.D., a professor of geriatric psychiatry at the University of Pittsburgh, and colleagues praised the study by Rovner and his team because “it breaks new ground.” They noted that few clinical trials have been undertaken to determine whether depression can be prevented in middle-aged and older adults with medical illnesses.

The study by Rovner and his group is also another indication that prevention may finally be coming of age in psychiatry. During the past decade, for example, resilience has garnered increasing attention from psychiatric researchers, an Air Force suicide-prevention program has been found effective, a cognitive-behavioral intervention delivered via the Internet has been found capable of preventing eating disorders, and a phone intervention has kept primary-care patients on the brink of a clinical depression from developing one.

The study was funded by the National Institute of Mental Health, National Eye Institute, and Farber Institute for Neurosciences of Thomas Jefferson University.

An abstract of “Preventing Depression in Age-Related Macular Degeneration” is posted at<http://archpsyc.ama-assn.org/cgi/content/abstract/64/8/886>.▪