Wales and West Vision Conference 2009
Depression and Sight Loss
Dr Daniel Smith
Clinical Senior Lecturer in Psychiatry
Depression
Robert Burton (1621)
“Melancholy is ….sorrow, need, sickness,
trouble, fear, grief, passion, or perturbation
of the mind ….. which causes anguish,
dullness, heaviness and vexation of spirit,
any ways opposite to pleasure, mirth, joy,
delight or a dislike ….. that is dull, sad,
sour, lumpish, ill-disposed, solitary, any way
moved, or displeased.
And from these melancholy dispositions no
man living is free ….. none so wise, none
so happy, none so patient, so generous, so
godly, so divine, that can vindicate himself;
so well-composed, but more or less, some
time or other, he feels the smart of it”.
What I’m going to cover……
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What is depression?
What causes it?
How common is depression in visual impairment?
Why is depression in people with visual
impairment important?
How should depression be treated?
The promise of Problem-Solving Treatment (PST)
DEPVIT: Depression in Visual Impairment Trial
Take home messages
What is depression?
MAJOR DEPRESSIVE EPISODE
Five or more of the following symptoms present for at least 2 weeks:
-depressed mood
-diminished interest or pleasure in almost all activities
-weight loss (or gain), or decrease or increase in appetite
-insomnia or hypersomnia
-psychomotor agitation or retardation (observable by others)
-loss or energy or fatigue
-feelings of worthlessness or guilt
-loss of concentration
-suicidal ideation
Depression is highly morbid
Depression is the 2nd leading cause of disability
worldwide in people aged 15-44
Depression costs the UK economy £12 billion per year
Depression
Lifetime risk: 10-20%.
Women: 2 times higher rate than men.
Course of illness: Recovery is the rule. However, a
relapsing course is common: 80% will have at least
one more episode in their lifetime.
The mean duration of an episode is 20 weeks.
Suicide in 10% of patients who have ever been
hospitalised for depression.
What causes depression?
Causes of depression
• Genetic predisposition (40% of risk)
• Early childhood adversity and stressful life events
• Physical illness
• Cognitive theories:
– ‘negative cognitive distortions’
– ‘depressogenic cognitive style’
• Biochemical abnormalities
– Reduced serotonergic and noradrenergic neurotransmission
• Endocrine abnormalities
– Hypercortisolaemia (HPA axis overdrive)
Causes of depression
• Genetic predisposition
• Early childhood adversity and stressful life events
• Physical illness, eg, visual impairment
• Cognitive theories:
– ‘negative cognitive distortions’
– ‘depressogenic cognitive style’
• Biochemical abnormalities
– Reduced serotonergic and noradrenergic neurotransmission
• Endocrine abnormalities
– Hypercortisolaemia (HPA axis overdrive)
Environmental
Srtess
The Stress-Vulnerability Model:
Gene x Environment interactions
Full blown disorder
Spectrum conditions
‘Normal’
Genetic predisposition
Depression is a ‘whole body’ disorder:
• Depressed patients:
– Have an increased risk of obesity and diabetes
– Are four times more likely than the general
population to have a heart attack
– Are more susceptible to infections because of
compromised immune systems
– Depressed women have decreased bone mineral
density and are at greater risk of hip fractures
– Often have additional risk factors for ill-health, eg,
they smoke more and use more alcohol
How common is depression in
visual impairment?
(3 studies)
Depression, visual acuity, comorbidity and disability
associated with age-related macular degeneration
Brody et al, 2001, Ophthalmology, 108:1893-1901.
• Cross-sectional baseline data from a RCT
• 151 patients (mean age 80) with advanced MD
• Formal diagnostic assessment
• 32.5% of participants had depressive disorder
(twice the usual rate in the elderly)
• Depression strongly associated with both visionspecific and general disability scores
Effect of depression on vision function
in age-related macular degeneration
Rovner et al, 2002, Arch Ophthalmol, 120:1041-1044.
• Follow-up study of 51 MD patients with recent
loss of vision in second eye
• Assessed at baseline and 6 months later
• 33% had depression at baseline:
– Poorer VA, greater visual disability, greater general
disability
• At six months follow-up, those whose depression
had worsened also had worsening visual and
general functioning
(independent of any change in visual acuity)
Depression and anxiety in visually
impaired older people
Evans et al, 2007, Ophthalmology, 114:283-288.
• Population-based cross-sectional study of 13,900
people aged 75 or over
• 13.5% of visually impaired had a score of 6 or more
on the Geriatric Depression Scale (compared to 4.6%
with good vision)
• No association between visual impairment and
anxiety
• Controlling for problems with activities of daily living
attenuated the association between visual
impairment and depression
How common is depression in visual
impairment?
• Estimates probably depend on the clinical
setting and severity and duration of visual
impairment
• At least 13.5% but probably closer to 33%
• Depression in VI profoundly influences
quality of life, general functioning, visual
functioning and ability to benefit from a
range of rehabilitation approaches
How should depression be treated?
How should depression be treated?
NICE Guidelines: stepped care model
“Bio-Psycho-Social” approach:
Antidepressants
Psychological treatments (eg, CBT)
Social interventions
The promise of Problem-Solving
Treatment (PST)
Problem-Solving Treatment
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A psychotherapy that teaches problem-solving skills
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Tackles negative perceptions which interfere with an
individual’s ability to find practical solutions to
problems
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Four key skills:
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Define the problem
Set a realistic goal
Generate, choose and implement a solution
Evaluate the outcome
Six one-hour sessions over 2 months
Preventing depression in age-related
macular degeneration
Rovner et al, 2007, Arch Gen Psych, 64:886-892.
• Randomised controlled trial of PST in 206 patients aged
65 or above with recent diagnosis of bilateral age-related
macular degeneration
• Outcome assessed at 2 and 6 months
• PST group significantly less likely to have depression at
2 months (11.6% versus 23.2% in controls)
• PST group also less likely to give up a ‘valued activity’
(this mediated the effect of PST on depression)
• By 6 months early benefits had diminished
“DEPVIT”: Depression in Visual
Impairment Trial
“DEPVIT”: Depression in Visual
Impairment Trial
• Tom Margrain, Cardiff University (PI)
• Danny Smith, Cardiff University
• Miles Stanford, St. Thomas’ Hospital, London
• Barbara Ryan, Cardiff University
• Catey Bunce, Moorfields, London
• Robin Casten, Philadelphia.
DEPVIT - aims
1. How common are depressive symptoms in
consecutive attendees of low vision services in
Cardiff and London (N=1000)?
2. Does Problem-Solving Treatment help to
reduce depression and improve functioning?
Randomised controlled trial (3 arms):
• Problem-solving treatment
• Letter to GP
• Waiting list control
DEPVIT – outcomes (N=100)
• Assessed at 2 months (questionnaires):
– Visual functioning
– Depressive symptoms
– Quality of life
• Assessed at 6 months (telephone interview):
– Visual functioning
– Depressive symptoms
– Quality of life
Take home messages
• Depression is a complex disorder
• People with visual impairment are at high risk of
depression
• Depression profoundly influences functioning, quality
of life and ability to benefit form other interventions
• Depression is treatable
• Problem-solving therapy is a promising new treatment
• The DEPVIT trial may lead to future changes in the
assessment and care of people with visual impairment