Living with the Black Dog

Our sight is arguably our most important sense. It’s something many of us take for granted yet its value becomes quickly apparent if we’re faced with its loss.

Not surprisingly, most people experience low moods as they come to terms with the reality of vision impairment and its impact on daily functioning and quality of life. This is a normal response to what is a difficult and life changing experience. However, low moods that are intense and persist for long periods of time can signal clinical depression.

According to beyond blue, depression is one of the most common mental health problems, affecting around one in five people in their lifetime.

The grant will fund a treatment program for early depression to be administered through low vision rehabilitation services

Winston Churchill used the euphemism of a ‘black dog’ to explain the clinical depression he was haunted by all his life.

As is true with all metaphors the term ‘black dog’ speaks volumes. It evokes both familiarity and an attempt at control. The dog may attack a person now and again but, as it is still just a dog, it can be put on a leash at other times.

Depression and Vision Loss

The rate of depression is significantly higher in people with vision loss. An estimated one third of older visually impaired adults show clinically significant depressive symptoms. Depression in older people can lead to serious consequences including increased illness, healthcare costs, mortality and suicide. It’s a growing problem. As the population ages, so too does the rate of vision loss and subsequent depression.

Depression in the visually impaired is an added source of disability. Their dual existence leads to a complex reciprocal relationship that is difficult to escape.

Risk factors for depression in the general population include gender, education, general health, disability, and level of social support. Vision loss is also a risk factor for depression and independent risk factors exist that are unique to people with vision loss. Understanding these unique causes is the first step to developing ways to detect, prevent and treat depression in people with vision loss.

Dr. Gwyneth Rees is a Senior Research Fellow at the Centre for Eye Research Australia (CERA), who has dedicated much of her career to investigating the link between vision loss and psychosocial issues.

Dr. Rees and her team have found that the primary source of depression in the visually impaired is the emotional distress caused by a person’s inability to function as normal. Typical emotional reactions to vision loss include worry, frustration, isolation, self-doubt and embarrassment.

Generic risk factors for depression, including poor physical health and negative life events, are also predictors of depression in people with vision loss. Interestingly, other generic risk factors such as gender and education appear not to be strongly associated with depression in this group.

The age that people experience vision loss is critical. Young people who are faced with vision loss are more likely to be depressed than older people in same circumstances. This may be due to the young being more affected by disruptions to work and family commitments or possessing less well-developed coping strategies than their older counterparts.

Depression Isn’t Inevitable

While vision loss is certainly a risk factor for depression, it isn’t an inevitable consequence. There are many examples of visually impaired people who live full and independent lives.

There are a number of widely available, proven treatments for depression. However, given the unique nature of depression in the visually impaired, it stands to reason that this group should receive tailored therapy. The research into vision-related risk factors for depression suggests that if people can continue to do the things they want to, they’re far less likely to become depressed.

Low vision rehabilitation can help people adjust to their circumstances and maintain their participation in many activities. Indeed, rehabilitation helps to make the transition seem less fraught. Research shows that rehabilitation services can lead to improvements in quality of life, self esteem and adjustment to vision loss.

Australia’s key low vision rehabilitation agency, Vision Australia, offers an excellent range of services, facilities and information to visually impaired people. Further, most services are provided free of charge.

Obstacles to Treatment

Given the range of treatment options, why do so many visually impaired people deal with the distress and added disability of depression that could be managed?

The most troubling aspect of Dr. Rees’ research is the high number of affected people who fail to seek treatment. One study found that just 20 per cent of visually impaired patients with depression are receiving treatment. Of those that were being treated, none were receiving psychological therapy.

Difficulties detecting depression in patients with chronic illness has been well documented. Studies have shown that GPs are less likely to ask older adults about their psychological and social well-being, and older adults are less likely to raise these issues.

Adding to this, visually impaired people have been identified as a group in which depression is least likely to be recognised by their GP.

Organisations like beyondblue and the Black Dog Institute have helped to break down some of the barriers surrounding depression. Despite this, stigma, discrimination and ignorance still plague the condition and the people who experience it.

A beyondblue project was conducted by Dr. Rees and her team into available psychological support systems for the visually impaired. The team conducted focus groups with Royal Victorian Eye and Ear Hospital staff and a statewide survey of eye-care practitioners and rehabilitation staff to understand current practice, barriers and training needs.

While the majority of practitioners interviewed acknowledged that depression is common among their patients, there are no services or processes available to address the problem.

The Solution

Eye-care practitioners and rehabilitation staff could be the much-needed conduit between depressed patients and their treatment.

Dr. Rees and her team recently developed a training program targeted at eye-care practitioners and low vision rehabilitation staff.

The training covers topics ‘Providing Emotional Support’ and ‘Grief, Depression and Self-Care,’ and instructs practitioners on how to spot the signs of depression, broach the subject with patients and refer patients for treatment.

An evaluation study found that practitioners reported increased competence and confidence in managing depression. It also increased the likelihood of practitioners responding to depressive symptoms in their patients. Recently, Vision Australia has integrated this training into their staff-development program.

Earlier this year, the National Health and Medical Research Council (NHMRC) also responded to the issue, awarding CERA a substantial grant to build on Dr. Rees’ early intervention strategies. The grant will fund a treatment program for early depression to be administered through low vision rehabilitation services.

Practitioners will learn how to spot depressive symptoms and offer psychological treatment as well as refer patients to appropriate services. The program assists people to adopt problem solving techniques and reduce avoidant behaviours using the widely recognised cognitive behavioural therapy (CBT) approach to depression treatment.

Dr. Rees and her team will work closely with Vision Australia to implement the program, with a pilot study being limited to Victoria with further scope for wider implementation.

Going Forward

While vision loss can have considerable psychological consequences, depression needn’t be inevitable. The recent contribution of funding by the NHMRC is a major step towards recognising and combating this issue. With appropriate training, eye care practitioners can eliminate unnecessary depression in this group by linking patients with much-needed treatment.

Professor Jonathan Crowston is a clinician-scientist who specialises in glaucoma and is the Managing Director of the Centre for Eye Research. He completed his ophthalmology training at Moorfields Eye Hospital, London and subsequent Fellowships at Westmead Hospital, Sydney and the Hamilton Glaucoma Centre, University of California, San Diego. His research is focused on age-related neurodegeneration and neuroprotection of the optic nerve.