Increased collaborations between optometry, ophthalmology,rehabilitation, behavioural psychology and psychiatry could halve levels of depression among AMD patients, according to a study published in Ophthalmology.
Julie Heraghty, CEO of Macular Disease Foundation Australia, says the study highlights the importance of low vision assessments, rehabilitation support, and the recommendation of low vision aids and technologies to ensure quality of life and independence for older Australians with macular disease.
“So often we talk to or meet with people with vision loss who almost accept that there is nothing that can be done to help them. But today there are so many technologies that are accessible – iPhones, iPads, text to speech technology for computers – that can help keep people engaged with the world around them.
The Low Vision Depression Prevention Trial (VITAL) recruited 188 participants with bilateral AMD from an ophthalmology practice affiliated with Wills Eye Hospital in Philadelphia.
Participants were 84 years of age on average, 70 per cent were women, and 50 per cent lived alone. All had a best-corrected vision of less than 20/70 and each participant had mild depressive symptoms and was assessed as being at risk of developing clinical depression.
During the trial, the participants had two visits with an optometrist, during which they were prescribed low-vision devices such as handheld magnifiers. After those initial visits, the participants were randomly split
into two groups.
One group received behaviour activation from an occupational therapist specially trained in the approach. The occupational therapist worked with participants to guide them on using the low-vision devices, to make changes around the home (such as using brighter lights and high-contrast tape), to increase their social activities, and to help them set personal goals and break these down into manageable steps.
“Blending the behaviour activation with low-vision rehabilitation was straightforward and natural,” said Dr. Mark Hegel, also a co-author and a professor of psychiatry at Dartmouth’s Geisel School of Medicine in Hanover, New Hampshire. “Occupational therapy helps people regain valued activities in their daily lives, and behaviour activation capitalises on this through formal goal setting and reinforcement of progress.”
The second group of participants served as a control group. They talked about their difficulties to a therapist, but did not receive behaviour activation or low-vision occupational therapy. Both groups had six one-hour therapy sessions in their homes over a two-month period. All participants were allowed to take antidepressants, but less than 10 per cent did so. All received medical management of AMD as prescribed by their primary eye care providers.
At four months, 12 participants in the control group and seven participants in the behaviour activation group had withdrawn from the trial or passed away. Of the remaining 169 participants, 18 (23.4 per cent) in the control group and 11 (12.6 per cent) in the behaviour activation group developed clinical depression.
Behaviour activation was most beneficial for participants with the worst vision (less than 20/100), reducing their risk of depression by about 60 per cent compared to controls. When the data were adjusted for vision status, physical health and baseline PHQ-9 score, behaviour activation reduced the risk of depression by 50 per cent compared to the control treatment.
Importance of Social Engagement
Ms. Heraghty said it was good to see involvement of Australian optometrists in referring to low vision services and increasingly offering such specialised services.
“Simple low vision devices supported by training, along with practical changes made to a person’s home, can make a huge difference both socially and emotionally to someone living with vision loss. This support can significantly improve a person’s quality of life, allowing them to continue to engage with family, friends and the wider community,” said Ms. Heraghty.
The National Disability Insurance Scheme (NDIS) as it stands today excludes people who acquire a disability over 65-years.
“The Foundation has been advocating strongly at every possible turn to ensure people who develop vision loss over 65 years have access to affordable low vision aids, technology and support. Given the present access for this age group is denied through the NDIS, the only pathway is presently through the aged care system,” said Ms. Heraghty.
“One of the key areas in aged care where access to support for those who have acquired a disability over the age of 65 years will be the Commonwealth Home Support Programme (CHSP).
“The CHSP aims to support older people, and their carers, so that they may continue living in their own homes for as long as possible. The CHSP will provide basic maintenance, care, support and respite services for older people living in the community, and their carers,” she said.
In the recent reforms to aged care, the federal government made changes that will introduce a single streamlined home support program on 1 July 2015.
Ms. Heraghty said the Foundation has campaigned for fair and reasonable access to low vision aids and technologies (LVATs) for many years.
The federal government released the draft Commonwealth Home Support Program (CHSP) in July 2014, providing an opportunity for reform to accommodate the needs of older people with a disability. This includes much needed LVATs for those with low vision.
“In response to the draft paper the Foundation submitted a strong case for appropriate inclusion of LVATs in this program and supported a holistic approach to assessment and support. This would enable the identification of other disease or conditions (co-morbidities) and provide services such as an Occupational Therapist (OT) assessment, mobility aids, home modifications, and personal assistance.
“If the Foundation’s recommendations on the CHSP were accepted, it would be a big first step in securing for those people living with low vision the support they need to enable independence and engagement, along with enhanced quality of life,” said Ms. Heraghty.
