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……

• 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 2 nd 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)

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 vision specific 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

• A psychotherapy that teaches problem-solving skills • • Tackles negative perceptions which interfere with an individual’s ability to find practical solutions to problems • 1.

2.

3.

4.

Four key skills: 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