Patients with visual impairment associated with high risk of depression: JAMA
Low vision negatively affects quality of life and is associated with reduced functional ability, increased disability, falls, social isolation, institutionalization, and mortality. Depression is common in older adults and even more common in those with visual impairment. Clinically significant subthreshold depression has been found in one-third of older adults with visual impairment, approximately twice as high as the lifetime prevalence rates in older adults without visual impairment, where depressive symptoms are present roughly in 15%.
Depression is a serious medical condition, and even mild symptoms may affect quality of life. Patients with vision loss may experience a greater burden of their disability, as depression is often accompanied by low energy levels, sleep problems, cognitive problems, or disproportionate worrying. Depression can also affect a person's learning capacity or the ability to retain information, make decisions, or achieve goals. Therefore, treatment of depression has increasingly gained attention within eye care settings as shown by numerous mental health care programs that have been tested and often found effective.
Depression screening has been recommended as a part of low vision services, with appropriate training of rehabilitation professionals and the use of standardized questions in both high-income and low-middle–income countries.
Mariacristina Parravano and team aimed to investigate this prevalence with the goal of developing public health strategies for people accessing eye services. They carried out a study to conduct a meta-analysis on the prevalence of depression in patients with visual impairment who regularly visit eye clinics and low vision rehabilitation services.
The meta-analysis included a search of MEDLINE (via PubMed) and Embase databases from inception to June 7, 2020. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Studies that obtained data on the association between acquired visual impairment and depression among individuals aged 18 years or older were identified and included in this review.
A total of 27 studies were included in this review, and all but 2 included patients older than 65 years. Among 6992 total patients (mean [SD] age, 76 [13.9] years; 4195 women [60%]) with visual impairment, in 1687 patients with depression, the median proportion of depression was 0.30.
The random-effects pooled estimate was 0.25 with high heterogeneity (95% predictive interval).
No patient characteristic, measured at the study level, influenced the prevalence of depression, except for the inclusion of patients with cognitive impairment (P = 0.008).
The prevalence of depression was high both in clinic-based studies (in 6 studies) and in rehabilitation services (in 18 studies vs other settings in 3 studies, P = 0.17), and did not vary by visual impairment severity of mild (in 8 studies), moderate (in 10 studies), and severe (in 5 studies, P = .51).
The results of this meta-analysis indicate that 1 in 4 patients with visual impairment who attended eye care services were affected by depression. Studies in this review included mostly patients aged 65 years or older. The finding of depression was similar, or even more common, among patients in clinical services compared with rehabilitation services, which could reflect patients' initial shock of receiving a diagnosis of an irreversible eye disease.
Alternatively, the lower rates of depression associated with rehabilitation services could be due to the fact that initiating low vision rehabilitation has beneficial effects on perceived depression, or it could be due to self-selection of patients who were less depressed seeking help in low vision services.
These results suggest that all primary and specialized eye care professionals, not only those working in low vision services, should have an appropriate knowledge of this topic and adequate clinical experience to decide when and how to investigate the presence of depression in people with visual impairment and eventually refer patients with depression for appropriate treatment. Treatment and follow-up visits of integrated care, which coordinates ophthalmologists and psychiatric or psychological referrals, may maximize efficiency and lead to effective patient centered care.
Given that depression is treatable and some ocular diseases that cause visual impairment are reversible, early identification and treatment of people most at risk for depression could be associated with their overall well-being.
The National Institute for Health and Care Excellence recommends that patients with positive screening results to at least 1 of 2 standard questions be referred to their general practitioner for appropriate assessment.
During the last month, have you often been bothered by feeling down, depressed, or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?
The results of this meta-analysis suggest that screening should occur in both low vision settings, such as rehabilitation clinics, and in primary care and general clinical settings, where a high prevalence of visual impairment has been reported. These findings also suggest that further research should address the clinical effectiveness of depression screening and treatment among patients with visual impairment.
This would mean integrating a screening protocol to detect and treat depression in general eye clinics, low vision, and rehabilitation settings. In cases of major depression, a patient should be referred to their general practitioner or directly to a psychiatrist for appropriate care.
Source: JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2021.1557