I.
Relevance of Clinical Depressive Disorders to Primary Care Optometry
A. Highly Prevalent in Primary Eye Care Settings
B. Leading Cause of Disability in Adults
C. Significant Morbidity (risk of suicide)
D. May Manifest itself with Ocular Symptoms
E. Intervention of O.D. can be Life Saving
II. Depression Defined
A. Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV)
B. Major Depressive Episode
1. Diagnostic criteria
a) Duration
b) Symptomatology
(1) Depressed mood
(2) Anhedonia
(3) Weight loss/gain
(4) Insomnia/hypersomnia
(5) Psychomotor agitation/retardation
(6) Fatigue/loss of energy
(7) Feelings of worthlessness/excessive guilt
(8) Cognitive impairment
(9) Suicidal ideations
c) Impairment
(1) Occupational
(2) Social
2. Unipolar versus bipolar depression
3. Diagnostic Coding
C. Dysthymia
1. Differentiation from major depressive disorder
2. Diagnostic Coding
D. Somatic, including Ocular, Symptoms that are Secondary to Depression
E. Medical Conditions that Mimic Depression
III. Etiology and Epidemiology
A. Age of Onset Typically in Early Thirties, but Substantial Variability
B. More Common in Women
C. Role of Neurotransmitter Deficiencies
D. Environmental Factors can Play a Role
1. Developmental
2. Current life stressors can contribute to depression
3. Depression can develop in the absence of obvious life stressors
E. Visual Loss can be a Contributing Factor in the Development of Depression
IV. Treatment
A. Pharmacological Treatment
1. Monoamine oxidase inhibitors (MAOIs)
a) Mechanism of action
b) Side effects (including ocular)
2. Tricyclics
a) Mechanism of action
b) Side effects (including ocular)
3. Selective seratonin reuptake inhibitors
a) Mechanism of action
b) Four – six week delay in effect
c) Advantages over first-generation antidepressants
d) Side effects (including ocular)
4. Dual-action antidepressants
a) Mechanism of action
b) Side effects (including ocular)
5. Initial pharmacological treatment effective in 50 – 60% of cases
6. Improving effectiveness of pharmacological interventions
a) Increase the dose and/or change the medication
b) Add a second medication to “boost” the effect
(1) Another antidepressant of a different class (e.g., Wellbutrin)
(2) Mood stabilizer (e.g., Lithium)
(3) Antipsychotics
7. FDA “Black Box” warning on antidepressants and suicidal ideations
B. Psychotherapy
1. Traditional psychoanalysis probably of limited effectiveness for treating depression
2. Cognitive behavioral therapy (CBT) is effective
a) Therapist helps client recognize distorted and maladaptive cognitions
(1) Black and white (all or nothing) thinking
(2) Catastrophizing
(3) Overgeneralizing
(4) Errors of inference
b) Therapist assists client to challenge and replace distorted/maladaptive
cognitions
3. Often combined with interpersonal and problem-solving therapy
C. Combined pharmacological and psychotherapeutic intervention is generally the most
effective treatment for depression
V. The Optometrist’s Role
A. Important to Intervene in Certain Cases
1. Could save a life and/or alleviate suffering
2. Practice management
B. Causes for Concern
1. History of depression
2. Currently being treated for depression
3. Abnormal affect, behavior, or cognitions
a) Lethargic
b) Hesitant/cognitively slow
c) Sad affect
d) Psychomotor agitation
e) Weight gain or loss
4. Recent change in occupational or social (e.g., marital) status
C. Two—Question Verbal Screener
1. Quick and easy to administer verbally
2. As sensitive and specific as longer, paper questionnaires
3. An affirmative answer to either question should lead to a strong suspicion of
depression
a) First question concerns mood over the past month
b) Second question concerns anhedonia over the past month
4. May be followed up with questions based on the DSM-IV diagnostic criteria if
necessary
D. The patient with visual loss
1. Which patients are most prone to depression?
2. A low vision referral is often indicated
VI. Making the Referral
A. Talking to your Patient
B. There are Many Different Licensed Professionals who Treat Depression
1. Primary care physicians
2. Psychiatrists
3. Psychologists
4. Mental health counselors (licensed professional counselors)
5. Clinical social workers
C. Provide your Patient with Several Referral Sources
D. Know your Referral Sources and their Treatment Strategies!
VII.
The Suicidal Patient
A. Elderly Men Most at Risk
B. Do Not Shy Away from Asking Questions about Suicidal Thoughts
C. A Suicide Plan and Means to Carry out the Plan Require You to Take Action
D. Do Not Let an Actively Suicidal Patient Leave your Office Unassisted!
VIII.
Reading References
1. Whooley MA, Simon GE. Managing depression in medical outpatients. N Engl J Med
2000;343:1942-50
2. Jampel HD, Frick KD, Kanz NK, Wren PA, Musch DC, Licht PR. Depression, mood
indicators, and self-reported visual function at baseline in the collaborative
glaucoma treatment study. Invest Ophthalmol Vis Sci 2006;47:ARVO E-Abstract
3463.
3. American Psychiatric Association. Diagnostic and Statistical Manual on Mental
Disorders, fourth edition (DSM-IV). Washington, DC: American Psychiatric Press,
1994.
4. Soroka M, Krumholz D, Bennet A. The practice of optometry: National Board of
Examiners in Optometry survey of optometric patients. Optom Vis Sci
2006;83(9):625-34.