Assessment of Mood and Adjustment Disorders in Individuals With Visual Impairment

Daniel Watson

3

BS, Ryan Kilpatrick

3

BS, Grace Yoon

3

BS, Laura Wool

2

PsyD, Tracy Williams

1

OD, and Felipe De Alba

1

MD Departments of Ophthalmology

1

and Psychiatry

2

, Loyola University Chicago Stritch School of Medicine

3

, Maywood, IL 60153

Introduction and Purpose

Introduction

Low vision is defined by the WHO as a visual acuity worse than 20/60 in the better eye [16]. Many diseases of the eye can cause a low vision state or blindness. In the developed world, these largely include age-related macular degeneration (AMD), diabetic retinopathy, and glaucoma. Glaucoma can often be treated successfully with intraocular pressure lowering drops. AMD and diabetic retinopathy, however, are chronic diseases with limited treatment options resulting in most cases of low vision. The prevalence of AMD is 2.8% in ages 40-59 and 13.4% in those 60 and above [10]. AMD is the cause of blindness in 18% of blind individuals 65-75 and 30% of blind individuals above 75 making it the leading cause of blindness in the developed world [14]. The prevalence of diabetic retinopathy is 28.5% with 4.4% of these being people with vision threatening retinopathy [17]. This makes diabetic retinopathy the most frequent cause of preventable blindness [12]. Studies have indicated that low vision states are associated with increased rates of depression similar to and even higher than other chronic diseases. A low vision state has been associated with depression rates twice that of the community dwelling elderly [4,5,6,14]. Moreover, the associated depression may be a greater contributor to disability than the patient's vision loss [4,6]. Complicating things more is the reciprocal relationship between depression and disability: depression worsens disability and disability worsens depression.

Figure 1

. Because of the influence of mood disorders on disability, it is therefore important to recognize and treat low vision patients with signs of depression in order to improve rehabilitation and quality of life.

Purpose

The purpose of this study is to determine the prevalence of mood disorders in a low vision study population. This will allow us to better understand how to recognize depression and anxiety in low vision patients and intervene in order to obtain better rehabilitation outcomes. This study will set a basis for future studies looking at visual impairment, mood disorders, disability, quality of life, and rehabilitation in low vision patients.

Background

Age-Related Macular Degeneration (AMD)

Age-Related Macular Degeneration is a disease process resulting in photoreceptor death. A lifetime of oxidative damage and genetic factors leads to the deposition of an acellular polymorphous material called drusen in the macula an area of the retina with a high density of rod and cone photoreceptors responsible for central vision.

Figure 2.

Fundus photograph showing the optic nerve to left with superior and inferior vessel arcades and central macula with encircling drusen deposits

Chronic inflammation also leads to local hypoxia and resulting neovascularization with complications of hemorrhage, edema, and fibrotic scarring. There are two types of macular degeneration: A patient is said to have “dry macular degeneration” when drusen deposits are seen. “Wet macular degeneration” is when evidence of neovascularization, hemorrhage, or edema is found. Risk factors, symptoms, and complications of AMD are listed in Table 1.

Risk Factors

• Increased age • Family history • Female sex • Caucasian Race • Obesity • Hypertension • Diet with high glycemic index • Smoking history • Heavy alcohol use

Symptoms

• Central vision loss • Scotomas or gaps in images • Metamorphopsia or distortion of straight lines

Table 1

.

Untreated Complications

• Low vision • Blindness

Background Continued

Progression of AMD is followed with regular eye exams, optical coherence tomography OCT, angiography, and fundus photography. Treatment includes an antioxidant vitamin regimen with zinc and lutein, anti-VEGF injections (ranibizumab/ Lucentis ® , bevacizumab/ Avastin ® , and aflibercept/ Eylea ® ) as well as photodynamic therapy (PDT) with verteporfin sensitization to eliminate weak blood vessels. The vitamin regimen has been shown to help prevent the conversion of dry macular degeneration to wet macular degeneration [1, 8, 11]

Diabetic Retinopathy

Chronic hyperglycemia results in damage to microvascular pericytes causing increased capillary permeability and weakness. Microaneurysms are the first sign of pathology. Resulting ischemia causes neovascularization, edema and hemorrhage. Retinal detachment can result secondary to edema or traction from vessel growth into the vitreous body.

Figure 3

.

Fundus photograph showing neovascularization of the optic nerve, dot-blot hemorrhages, and cotton wool spots There are two types of diabetic retinopathy. Background diabetic retinopathy with characteristic microaneurysms occurs in 80-95% of cases. This progresses to blindness in 5 years in 5-20% of cases. Proliferative diabetic retinopathy is characterized by neovascularization and hemorrhage occurring in 5-10% of cases with 50% of these progressing to blindness in 5 years. Risk factors, symptoms, and complications of diabetic retinopathy are listed in Table 2.

Risk Factors Symptoms Table 2

.

Untreated Complications

Poor glycemic control Duration of diabetes Younger age of onset African American, Hispanic, and South Asian race Pregnancy Puberty Generally symptomless until the disease has progressed significantly indicating why it is important for yearly diabetic eye exams Loss of vision may be due to hemorrhage, edema, or secondary retinal detachment Diabetes can also cause blurred vision due to the osmotic effects of hyperglycemia on the lens of the eye as well as diplopia or double vision due to ischemic damage to the nerves that control the extraocular muscles of the eye Blindness Vitreous hemorrhage Fibrous scarring Retinal detachment Microneuropathic damage to CN II, III, IV, VI Progression of diabetic retinopathy is followed with regular eye exams, optical coherence tomography OCT, angiography, and fundus photography. Treatment includes control of hyperglycemia and dyslipidemia, anti-VEGF injections, and laser photocoagulation [3, 7, 9].

Measuring Visual Impairment

Visual impairment in this study was measured using the National Eye Institute’s Visual Functioning Questionnaire –25 (NEI VFQ-25). It is a 25 question test which provides a composite score from 0-100 with 100 correlating to 100% functionality and the least visual impairment. It has been validated across different eye diseases [13].

Mood Disorders

Depression is defined by the DSM-IV-TR criteria as at least 5 of the symptoms in Table 3 (including 1 of 2 core symptoms: depressed mood/ irritable mood or loss of interest or pleasure) present during the same 2-week period for most of the day nearly every day.

Table 3. Symptoms of Depression

• Insomnia or hypersomnia • Significantly decreased interest or pleasure in in almost all activities • Feelings of worthlessness or excessive inappropriate guilt • Fatigue or loss of energy • Indecisiveness or decreased ability to concentrate • Significant change in weight or appetite • Psychomotor agitation or retardation nearly every day (observable by others) • Recurrent thoughts of death or suicide General anxiety is characterized by the DSM-IV-TR as excessive anxiety and worry about multiple concerns which occurs more days than not for >6 months with patients finding it difficult to control this worrying and at least 3 symptoms found in Table 4 [2].

Table 4. Symptoms of General Anxiety

• Feeling restless, fidgety, jittery, keyed-up, or on edge • Easily fatigued • Problems with concentrating • Irritability • Muscle tension • Sleep disturbance

Screening for Depression and Anxiety

The Center for Epidemiological Studies Depression (CES-D) can be used as a screening test for depression. It is made up of 20 questions graded from 0-3 for a total score ranging from 0 to 60. A score greater than 16 is considered depressed and a score greater than 25 is considered majorly depressed . The average score of depressed individuals was 38.10 +/- 9.01 when compared to the gold standard of diagnosis using the Structured Clinical Interview for DSM-IV Axis I Disorders [12]. The Generalized Anxiety Disorder-7item (GAD 7) is used to screen for generalized anxiety. It is made up of 7 questions scored 0-3 for a total score ranging from 0 to 21. Greater than 5 is considered mild anxiety, 10 moderate anxiety, and 15 severe anxiety. Average score of those with anxiety is 14.18 +/- 5.57 [15].

Methods

Study Design

This was a cross-sectional survey in which patients attending appointments in the low vision/retina clinic in the Loyola Outpatient Center were consecutively screened for enrollment into the study. Inclusion criteria was: age 18 and above, low vision status of a best corrected visual acuity (BCVA) of 20/60 or worse in the better eye, and visual impairment caused by only one pathological process. Exclusion criteria was psychiatric diagnosis prior to onset of visual impairment, current mental health treatment , use of psychotropic medication, current substance abuse; or inadequate hearing or cognition for completion of an interview.

Data Collection

Eligible patients were consented and three surveys were administered via interview. These included: the generalized anxiety disorder 7-item (GAD-7), the center for epidemiologic studies depression scale (CES-D), and the national eye institute visual functioning questionnaire (NEI VFQ-25). All of these have been validated and found reliable for use in the general population [12,13,15]. The interview was conducted by investigators trained in the proper administration of the GAD-7, CES-D, and NEI VFQ-25. The following other information was gathered: age, sex, race, visual acuity, ophthalmologic diagnosis, past history of rehabilitation, comorbid diagnosis including psychiatric diagnoses and their management, past relevant surgical history, family history of eye disorders or depression or anxiety, substance abuse history, living situation, social support, and marital status. Information regarding comorbid psychiatric diagnosis and treatment was obtained from the patient verbally and voluntarily not through chart review.

Data Analysis

Consecutive screening took place in the retina clinic over several weeks until 80 patients were successfully enrolled and interviewed. The GAD-7, CES-D, and NEI VFQ-25 surveys were scored and results evaluated. Statistical analysis consisted of the calculation of prevalence rates for depression and anxiety in our study population. Regression analysis and correlation coefficients were also calculated.

Preliminary Results and Discussion

Preliminary Data

Since this study is still ongoing, preliminary data is only available. Table 5 is a snapshot of raw data.

Record Number GAD-7 Score CES-D Score NEI VFQ-25 Score % Visual Acuity Table 5. Primary Disease Process

1 2 3 4 5 6 1 1 0 4 0 4 13 8 1 28 10 31 51 54 66 48 65 13 20/200; 20/60 20/100; 20/200 PH 20/100; 20/40 20/100; 20/60 20/80; 20/100 20/100; CF PH 20/80, CF 20/70; 20/60 PH 20/60; NI Diabetic Retinopathy Diabetic Retinopathy Diabetic Retinopathy Diabetic Retinopathy Diabetic Retinopathy Diabetic Retinopathy 7 8 9 9 0 12 19 4 49 44 54 68 1.5/200; 1/200 NLP; NLP 3/200; 4/200 Diabetic Retinopathy Diabetic Retinopathy AMD Where a GAD- 7 score of 5 indicates mild anxiety, 10 moderate anxiety, and 15 severe anxiety; a CES D score of 16 is depressed and greater than 25 is majorly depressed; and NEI VFQ-25 composite score indicates percent functionality (N=9).

Figure 4.

Discussion

Inferences made from this data is limited due to the ongoing nature of this study and the need for more completed interviews. As the number of interviews are completed, the prevalence percentages in Figure 4 (55.5% euthymic, 22.2% depressed, and 22.2% majorly depressed) may change drastically. Interesting observations of the raw data include individual number 6 who has a CES-D score indicating major depression and a NEI VFQ 25 score indicating severe loss of functionality; however, this person’s visual acuity is one of the best listed. Another interesting observation is individual 8 who has the worst visual acuity (no light perception, NLP) yet has some of the lowest scores on the GAD-7 and CES-D. Upon further questioning, this individual had undergone low vision rehabilitation and could be said to have a very positive outlook despite his disability.

There are many challenges in this research. It is survey based and a wide variety of surveys for anxiety, depression, and visual impairment are available. This makes it difficult to compare results between studies as many choose to use different measures. Also because our study population is significantly visually impaired, the surveys must be

Discussion Continued

read to each individual. This requires that each survey be presented in an interview format by a designated investigator. Other variables that make this type of research difficult is that visual acuities can fluctuate greatly in AMD and diabetic retinopathy between visits sometimes making patients eligible for participation at one visit but not another. The timing of vision loss could also be a confounder as patients with acute vision loss may have not had enough time as those experiencing chronic vision loss to cope and adapt to their impairment.

Conclusions and Future Directions

Screening for mood disorders in individuals with low vision is important because it can add significantly to a patient’s disability level and adversely affect rehabilitation efforts. Initial interviews with low vision patient’s should include a mood disorder screening measure and appropriate referral to mental health and low vision specialists. Discussions should explore the patient’s understanding of their condition, the worries they have about their vision loss, and the limitations they are experiencing because of their eye sight. Future directions in this research include studies measuring the rates of mood disorders after mental health treatment and low vision rehabilitation.

Summary

•

Low vision is defined by the WHO as a visual acuity worse than 20/60 in the better eye.

•

Age-related macular degeneration and diabetic retinopathy are two of the most common causes of low vision and blindness in the developed world.

•

Studies have shown that high rates of depression also occur in patients with low vision and contribute to disability.

•

We report preliminary data for the prevalence of depression in patients attending the retina clinic at Loyola. We also discussed strategies and challenges in studying the low vision population.

•

We showed that it is important to screen for signs of depression in low vision patients. Treating concomitant mood disorders will be important in facilitating improved rehabilitation and quality of life.

•

We also explored future directions in this research.

References

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2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., text rev. Washington, DC: 2000.

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