RCT
Notes: a Effect size is calculated as ([intervention group mean change] – [control group mean change])/(preintervention SD); b Partial eta squared where small=0.10, medium=0.30 and large=0.50.
Abbreviations: ACS, Activity Card Sort; AMD, age-related macular degeneration; AMD-SEQ, Macular Degeneration Self-Efficacy Scale; AVLS, Adaptation to Vision Loss Scale, Adaptation to Vision Loss Scale – 12 item; DASS, Depression, Anxiety, Stress Scale; DSSI-11, Duke Social Support Index 11 item; GDS-125, Geriatric Depression Scale; GSES, Generalized Self-Efficacy Scale; IVI, Impact of Vision Impairment Questionnaire, LOT-R, Life Orientation Test–Revised; NEI-VFQ, National Eye Institute Visual Function Questionnaire; POMS, Profile of Mood States; QWB, Quality of Well-Being Scale; SF-35, Short Form-36 Health Survey; SM, self-management.
Problem-solving treatment (PST) may also be beneficial for individuals with vision impairment. PST is a manualized intervention that involves learning skills such as how to define problems, establish realistic goals, generate, choose, and implement solutions, and, finally, evaluate outcomes. 143 , 144 PST is a brief intervention that can be delivered by non-specialists (ie, general practitioners, nurses) and thus has applicability for primary care settings. 143 , 145 Randomized controlled trials in general psychiatric samples indicate that PST is equally as effective as antidepressant medication alone, and the combination of PST and antidepressant medication in managing depressive symptoms. 146 In a randomized control trial comparing the effects of PST to usual care, PST was more effective in preventing depression in older adults with AMD after two months, but the difference between the interventions was no longer significant after six months. 144 , 147 Thus, PST may delay the onset of depression in people with AMD, however, additional sessions or booster treatments may be necessary in order to prevent the emergence of depression as time goes on and the condition worsens. 144 , 147 Additionally, another study found that 6–8 sessions of PST delivered to older adults with vision loss and significant (ie, moderate-to-severe) depressive symptoms led to a reduction in depressive symptom scores, but the change was not clinically significant. 120 Nevertheless, PST may offer several advantages over other treatment approaches. For example, in many cases PST is delivered by Master’s or Bachelor’s level clinicians or nurses (eg, 48 , 102 , 144 ), thereby expanding patient access to treatment. More recently, PST was delivered to individuals with vision impairment and significant depressive symptoms via phone (ie, telehealth). 148 After three months, participants reported significant improvement in depressive symptom severity, health-related quality-of-life, and confidence in using problem-focused coping skills. 148 Additionally, one mechanism by which PST may be effective is by encouraging continuation of valued activities. 144 This is an important aspect of treatment given the association between functional decline and depression in people with vision loss. 36 , 42 , 102 In comparison to supportive therapy, PST demonstrated similar outcomes in terms of activity engagement, self-reported visual function, physical health status, and depressive symptom severity in people with AMD. However, PST has led to greater improvements in vision-related quality-of-life and increased use of adaptive coping strategies at 3- and 6-months post-treatment. 149 Notably, while PST and supportive therapy are similar, PST is unique in its incorporation of problem-solving skills training. Thus, learning effective methods for solving problems may be especially beneficial for people with vision loss ( Table 2 ).
Problem-Solving Treatment (PST)
Study | Sample | Intervention | Control | Outcomes Assessed | Main Findings |
---|---|---|---|---|---|
Rovner et al , RCT | 206 adults ages 64+ with AMD, neovascular AMD in one eye diagnosed within the past 6 months and pre-existing AMD in the other eye | N=105: Six 45–60 minute in-home sessions over 8 weeks, consisting of problem-solving skills (ie, how to define problems, establish realistic goals, generate, choose, and implement solutions, and evaluate outcomes); treatment is delivered by trained therapists and nurses | N=101: Usual care | Depressive disorder diagnosis Depressive symptoms (HDRS) Self-rated vision disability (NEI-VFQ) Mediators: Loss of values activities Covariates: Pre-intervention scores | Two months after intervention end, 23.2% of the usual care group met criteria for a depressive disorder, while only 11.6% of patients in the PST group met criteria; participants who received PST were less than half as likely to develop a depressive disorder ( =0.03) Six months after intervention end there was no significant difference between groups in depressive disorder prevalence In the PST group, only 36.4% of patients who met criteria for depression at treatment end were depressed at 6 months, whereas 72.2% of controls remained depressed throughout the follow-up period, suggesting PST may have delayed the onset of depression, but additional sessions may have been needed in order to prevent the emergence of depression altogether Participants receiving PST were less likely to relinquish a valued activity, which was identified as a mediator in the relationship between PST and reduced depression at 2 months ( =0.02) PST participants reported improved subjective vision function at 2 months, despite no change in objective acuity ( =0.04) 34 of 49 subjects reporting minimal depressive symptoms developed a depressive disorder within 6 months 75.6% of those reporting minimal depression at baseline developed a depressive disorder at 2 or 6 months, compared to 17.8% of those reporting even fewer depressive symptoms |
Rovner et al RCT | 241 adults ages 65+ with bilateral AMD (neovascular and/or geographic atrophy), visual acuity between 20/70 and 20/400 in the better-seeing eye, and moderate difficulty in a valued vision-function goal (eg, reading mail, attending social activities) | N=121: Sessions consisting of problem-solving skills (ie, how to define problems, establish realistic goals, generate, choose, and implement solutions, and evaluate outcomes); treatment is delivered by trained BA and MA level therapists | N=120: Supportive therapy (similar to PST, but no problem-solving skills training) | Targeted vision function (Activities Inventory) Vision function and quality-of-life in relation to vision (NEI-VFQ) Vision status (visual acuity, contrast sensitivity, central scotomas) Physical health status (CDS) Depressive symptoms (PHQ-9) Coping strategies (OPS) Covariates: Pre-intervention scores and vision severity stratification | After 3 and 6 months, both groups had similar improvements in targeted vision function scores No between- or within-group changes in depressive symptoms, vision function, or use of low vision devices were observed at 3 or 6 months Participants receiving PST had greater improvements in vision-related quality-of-life ( =0.05; =0.05) and increased use of adaptive coping strategies ( <0.0001; =0.015) 3 and 6-months post-treatment compared to those receiving supportive therapy |
Nollett et al RCT | 85 adults ages 18+ (mean age range 67–72), attending a low-vision center, with significant depressive symptoms (GDS-15 ≥6) | N=24: PST (6–8 45–60 minutes in-home sessions, consisting of problem-solving skills such as how to define problems, establish realistic goals, generate, choose, and implement solutions, and finally, evaluate outcomes) N=31: Physician referral | N=20: Waitlist | Depressive symptoms (BDI-II; GDS‐15) Self-rated vision disability (NEI-VFQ) Near visual function (VFQ-48) Health-related quality-of-life (EQ-5D) Mediators: Social Support (DSSI-11); Optimistic vs pessimistic outlook (LOT-R); Self-Efficacy (AMD-SEQ) | A similar reduction in depressive symptom severity was observed across all groups 6 months after intervention end; participants with moderate-to-severe depressive symptoms at baseline demonstrated the greatest reduction Changes in depression scores in the intervention groups did not reach clinical significance |
Holloway et al | 62 adults ages 18+ (mean age 62) with vision impairment, visual acuity <6/12 in the better-seeing eye (with correction), with at least mild depressive symptoms (PHQ-9 ≥5) | N=62: telephone-administered PST (6–8 45–60 minute telephone sessions, consisting of problem-solving skills such as how to define problems, establish realistic goals, generate, choose, and implement solutions, and finally, evaluate outcomes) | None | Depressive symptoms (PHQ-9) Vision-related quality-of-life (AQoL-7D) Confidence in ability to use problem-focused coping (CSE) | 37 participants withdrew from PST treatment over the course of the study, leaving only 25 completers (6–8 sessions) A 53% reduction in depressive symptom severity was observed at follow-up ( <0.001) In 67% of participants change in depressive symptom severity was clinically meaningful (PHQ-9 change ≥5 points) Clinically meaningful improvements in vision-related quality-of-ife ( <0.001), independent living ( =0.02), mental health ( =0.001), and coping ( =0.03) was observed following treatment Participants’ confidence in their ability to use problem-focused coping strategies improved by 18% ( =0.001) at treatment end |
Abbreviations: AMD, age-related macular degeneration; AMD-SEQ, AMD Self-Efficacy Questionnaire; BDI-II, Beck Depression Inventory; CDS, Chronic Disease Score; CSE, Coping Self-Efficacy Scale; DSSI-11, Duke Social Support Index-11 item; EQ-5D, EuroQol Five Dimensions Questionnaire; GDS‐15, Geriatric Depression Scale; HDRS, Hamilton Depression Rating Scale; LOT-R, Life Orientation Test–Revised; NEI-VFQ, National Eye Institute Visual Function Questionnaire; OPS, Optimization in Primary and Secondary Control Scale; PHQ-9, Patient Heath Questionnaire; PST, problem-solving treatment; VFQ-48, Visual Function Questionnaire; AQoL-7D, Vision-Related Assessment of Quality-of-Life.
Another behavioral intervention that may hold promise for improving psychiatric symptoms in visually impaired populations is vision rehabilitation. These programs typically involve a combination of low vision clinical services (eg, prescription of adaptive devices and instruction on use), rehabilitation training (eg, skills of daily living), orientation and mobility training (eg, safe travel procedures), and counseling and support groups to help with adaptation to disability and improve quality-of-life. 150 The primary aim of vision rehabilitation programs is to maintain or improve an individual’s current level of functioning. However, by promoting self-efficacy, vision rehabilitation may also lessen depression risk in people with visual impairment. 151 Importantly, studies have found that specific treatment components of low vision clinical services, counseling, and the use of optical devices were associated with significant change in depression scores, whereas skills training and the use of adaptive devices were not. 151 , 152 Despite these findings, counseling services are typically only offered as a supplement to functional rehabilitation, and, in one study, were received by as few as 16% of participants. 151 Thus, while targeting visual functioning may also have an impact on psychological functioning in elderly adults with vision loss, directly addressing the emotional aspects of vision loss is a necessary part of treatment that may lead to more robust improvements in mental health ( Table 3 ).
Vision Rehabilitation Interventions
Study | Sample | Intervention | Control | Outcomes Assessed | Main Findings |
---|---|---|---|---|---|
Horowitz et al | 95 adults ages 65+ newly referred to a vision rehabilitation program | N=95: A combination of low vision clinical services (eg, prescription of adaptive devices and instruction on use), skills training (eg, skills of daily living, orientation and mobility training), and counseling depending on the needs and preferences of the individual | None | Vision rehabilitation service utilization (low vision clinical services, skills training, and counseling) Number of optical aids used (eg, magnifiers, special sunglasses) Number of adaptive aids used (eg, talking books, large print reading materials, large print telephone dial, special lighting) Depressive symptoms (CES-D) Covariates: Age; health status; vision status; functional disability; baseline depressive symptoms | Low vision clinical services was the most commonly used treatment component (received by 78% of sample) Approximately 21% of the study sample reporting baseline depression remained depressed at follow-up, while 13% experienced remission Greater use of low vision services ( <0.01), skills training ( <0.05), and optical ( <0.01) and adaptive ( <0.05) aids was associated with fewer depressive symptoms after 2 years Low vision clinical services significantly explained an additional 5% of the change in depressive symptom scores after 2 years ( <0.01), and counseling and use of optical devices each explained an additional 3% ( s<0.05) |
Horowitz et al | 584 adults aged 65+ newly referred to a vision rehabilitation program and with functional onset of the vision problem within the past 5 years | N=95: A combination of low vision clinical services (eg, prescription of adaptive devices and instruction on use), skills training (eg, skills of daily living, orientation and mobility training), and counseling depending on the needs and preferences of the individual | None | Functional disability (OMFAQ; IADL) Number of optical aids used (eg, magnifiers, special sunglasses) Number of adaptive aids used (eg, talking books, large print reading materials, large print telephone dial, special lighting) Depressive symptoms (CES-D) Covariates: Pre intervention scores; sociodemographic factors; rehabilitation service hours | Optical aids were used by 91% of the sample Greater use of optical aids after 6 months was associated with less functional disability ( <0.001) and fewer depressive symptoms ( <0.05) after 6 months Greater use of adaptive aids was associated with greater disability at after 6 months ( <0.001) The use of optical aids was associated with less functional disability ( <0.001) and fewer depressive symptoms ( <0.05) at 6 months Greater functional disability at baseline was a significant predictor of depressive symptom severity at 6 months ( <0.05) |
Abbreviations: CES-D, Center for Epidemiological Studies Depression Scale; IADL, instrumental activities of daily living; OMFAQ, Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire.
Among individuals with AMD, modified cognitive-behavioral interventions have been used to improve depression and anxiety symptoms, with some success. In one study, a single component of cognitive behavioral treatment, behavioral activation, in conjunction with low vision rehabilitation was significantly more effective in preventing depression in patients with AMD compared with supportive therapy combined with low vision rehabilitation. 153 A follow-up mediation analysis demonstrated that improvement in depression scores following behavioral activation and low vision rehabilitation was explained by an increase in social engagement. 153 Self-guided CBT has also led to a significantly greater reduction in depressive symptoms among patients with AMD relative to usual care, although improvements in other outcomes, including anxiety and self-efficacy, were not observed. 154 Cognitive and behavioral approaches have also been tested in other visually impaired populations, such as people with blindness. In one study, individuals with blindness receiving Rational Emotive Behavior Therapy (REBT), a type of cognitive therapy, reported significant reductions in irrational beliefs, depression, anxiety, and stress and improvements in self-esteem, while these same changes were not observed in the control group. 113 Moreover, these mental health effects were maintained in the REBT group up to 1-month post-treatment. 113 Together, these findings suggest that cognitive behavioral interventions may be effective in improving psychological functioning of adults with varying degrees of vision loss ( Table 4 ).
Cognitive Behavioral Therapy (CBT) Interventions
Study | Sample | Intervention | Control | Outcomes Assessed | Main Findings |
---|---|---|---|---|---|
Rovner et al RCT | 188 adults aged 65+ with bilateral AMD (neovascular or geographic atrophy), visual acuity <20/70 in the better seeing eye with correction, moderate difficulty performing a valued vision-dependent activity, and subthreshold depressive symptom | N=96: BA+LVR consisting of six in-home 1-hour BA sessions over 8 weeks, focusing on promoting self-efficacy and social connection to improve mood and function, and action plans to accomplish personal and functional goals | N=92: ST+LVR consisting of six in-home 1-hour BA sessions over 8 weeks, focusing on personal expression about vision loss (ie, discussion of illness, disability, and vision loss) | Depressive disorder diagnosis (based on PHQ-9) Vision function and quality-of-life in relation to vision (NEI-VFQ; Activities Inventory) Vision status (visual acuity, contrast sensitivity, central scotomas) Physical health status (CDS; MOS-6) Personality (NEO-PI-R) Behavioral activation (BADS) Optical device use Mediators: Social impairment Covariates: Pre-intervention scores; visual acuity | At 4 months, the absolute risk reduction for the BA+LVR group was 11% and the number needed to treat to prevent one additional case of depression was nine Participants receiving BA+LVR were significantly less likely to develop a depressive disorder after 4 months compared to those receiving ST+LVR ( =0.04) Vision function improved in both groups, but the effect was larger in BA+LVR (effect size =0.72) group Social impairment was a partial mediator of the relationship between treatment group and depression-BA+LVR prevented depression to the extent that it increased social engagement |
Kamga et al RCT | 80 adults aged 50+ with late stage AMD or diabetic retinopathy, acuity in both eyes better than 20/200, and mild depressive symptoms | N=41: Self-guided CBT toolkit consisting of cognitive restructuring, problem-solving, and mood monitoring and telephone coaching with three 10-minute calls over 8 weeks | N= 39: Usual care | Depressive symptoms (PHQ-9) Anxiety symptoms (GAD-7) Life space (LSA) Self-efficacy (DMSES) Covariates: Visual acuity; psychiatric history (eg, antidepressant, psychotherapy use) | After 8 weeks, there was a significant reduction in depression scores in both groups, but depressive symptom scores in the CBT group were slightly lower (1.7 points) than that of the usual care group (effect size =0.39) The CBT intervention was not associated with significant improvements in other outcomes (anxiety, life space, self-efficacy) |
Jalali et al RCT | 60 adults aged 20–40 with late blindness | N=30: REBT (a type of cognitive therapy focused on changing irrational beliefs) | N=30: Unspecified | Irrational beliefs (IBT) Psychological well-being (DASS-21) Self-esteem (ESEI) | Participants receiving REBT reported significant reductions in irrational beliefs (effect size =2.0), depression (effect size =3.2), anxiety (effect size =2.3), and stress (effect size =2.7) and improvements in self-esteem (effect size =1.9), while these same changes were not observed in the control group The positive effects of REBT were maintained 1 month after intervention end |
Notes: a Cohen’s d estimate of effect size where small=0.20, medium=0.50 and large=0.80.
Abbreviations: AMD, age-related macular degeneration; BA+LVR, behavioral activation + low vision rehabilitation; BADS, Behavioral Activation for Depression Scale; CBT, cognitive behavioral therapy; CDS, Chronic Disease Score; DASS-21, Depression, Anxiety, Stress Scale – 21 item; DMSES, Diabetes Self-Care Self-Efficacy Scale; ESEI, Eysenck’s Self Esteem Inventory; GAD-7, Generalized Anxiety Disorder inventory; IBT, Jones Irrational Beliefs Questionnaire; LSA, Life-Space Assessment; MOS-6, Medical Outcomes Study-6; NEI-VFQ, National Eye Institute Visual Function Questionnaire; NEO-PI-R, Revised Neuroticism, Extroversion, Openness Five Factor Inventory; PHQ-9, PHQ-9 Patient Heath; REBT, rational emotive behavior therapy; ST+LVR, supportive therapy + low vision rehabilitation.
Stepped Care Interventions
In the last decade, stepped care has been a recommended approach to treating individuals with mild-to-moderate levels of depression and anxiety. 155 Stepped care has also demonstrated success in reducing the incidence of depressive and anxiety disorders among older adults in the general population who experience subthreshold symptoms. 156 Stepped care increases efficiency of behavioral health care delivery by initially providing patients with the least intensive interventions and then moving to more intensive services as required (ie, if symptoms remain near baseline levels). 157 In a multi-site randomized control trial, van der Aa et al 157 tested the effectiveness of stepped care in ameliorating depression and anxiety in older adults with vision loss. Compared to individuals receiving usual care, those in the stepped care group reported significantly greater improvements in depressive and anxiety symptoms and vision-related quality-of-life at treatment end. 157 Older adults receiving stepped care were also less likely than controls to develop depressive or anxiety disorder over a 2-year follow-up period. However, 25–30% of elderly patients in the stepped care group that qualified for guided self-help or PST were either non-compliant or not fully adherent to treatment protocols and reported finding these steps to be unnecessary or too burdensome. 157 Additionally, a considerable number (~30%) of older adults receiving stepped care developed depression, though half of these individuals reported a history of depressive or anxiety disorders. 157 Thus, while stepped care may be effective in preventing the onset of mental health problems in older adults with vision impairment, it may be less effective in preventing the recurrence of depression in those with preexisting or past symptoms. As anxiety and depression are relatively common in the population at large, and may be especially prevalent among individuals with vision impairment (reviewed above), this signifies a significant limitation of this approach, although it is a limitation shared with many other interventions for many other health conditions. Nevertheless, stepped care has demonstrated superiority to usual care in terms of cost-effectiveness. 158 Therefore, stepped care models may offer some advantage over traditional approaches in targeting mental health problems in older adults with vision impairment ( Table 5 ).
Study | Sample | Intervention | Control | Outcomes Assessed | Main Findings |
---|---|---|---|---|---|
Van der Aa et al RCT | 265 adults aged 50+ with visual impairment, decimal visual acuity of ≤0.3 and/or a visual field of ≤30°, and subthreshold depression and/or anxiety (≥8 on the (HADS-A) (CES-D) | N=131: Four consecutive steps, each approximately 3 months: watchful waiting, guided self-help based on CBT, PST, and referral to the general practitioner. Participants with increased symptoms of depression and/or anxiety (score of ≥8 on the HADS-A and/or ≥16 on the CES-D) were moved to the next step. | N=134: Usual care (outpatient low vision rehabilitation care and/or care that was provided by other healthcare providers) | Depressive disorder diagnosis Depressive symptoms (CES-D) Anxiety symptoms (HADS-A) Vision-related quality-of-life (LVQoL) Adaptation to vision loss (AVL) Health-related quality-of-life (EQ-5D) Covariates: Sociodemographic factors, acuity, psychiatric history | 29% of participants in the stepped care group and 46% in the usual care group developed a depressive and/or anxiety disorder over the 24-month follow-up; stepped care participants were significantly less likely to develop a depressive and/or anxiety disorder ( =0.01) Participants receiving stepped care had greater improvements in depressive ( =0.02) and anxiety ( =0.04) symptoms and vision-related quality-of-life ( =0.02) relative to the control group Approximately 25–30% of participants in the stepped care group that qualified for guided self-help or PST were either non-compliant or not fully adherent and reported finding the steps to be unnecessary or too burdensome |
Abbreviations: AVL, Adaptation to Vision Loss scale; CBT, cognitive behavioral therapy; CES-D, Center for Epidemiological Studies Depression Scale; EQ-5D, EuroQol Five Dimensions Questionnaire; HADS-A, Hospital Anxiety and Depression Scale–Anxiety Subscale; LVQoL, low vision quality-of-life; PST, problem-solving treatment.
Although studies of behavioral interventions for the prevention and treatment of mental health problems in people with vision impairment have reported some positive results, these treatments are lacking in several ways. Many of these interventions are focused almost exclusively on improving functionality through skills training. 144 , 151 Though functional impairment has been linked to depressive symptoms in individuals with vision impairment, 36 , 102 vision-specific distress has also been identified as an important contributor to depression in this population. 12 Therefore, more targeted interventions for psychological and emotional difficulties associated with vision loss may be needed. Indeed, Wahl et al 159 compared the effects of an emotion-focused treatment with a problem-focused approach in patients with AMD and found that, while problem-solving therapy was associated with an increase in active problem orientation and adaptation to vision loss, only those in the emotion-focused therapy group experienced a significant decrease in depressive symptoms (though the effect size was small). Additionally, many current treatments for mental health problems in people with vision impairment are severely limited in their effectiveness. Findings from a meta-analysis indicate that, overall, psychosocial interventions have a small significant effect on improving depression in people with vision impairment, and this effect is linked with age, whereby lower age was associated with better outcomes. 160 However, after removing a study outlier with a small sample size, younger age of participants, and shorter follow-up period, the effect of the included interventions on depressive symptoms was no longer significant. 160 Similarly negligible results were obtained for anxiety symptoms, with psychosocial interventions leading to a medium-sized reduction in anxiety symptoms in comparison to control conditions, without statistical significance. 160 Likewise, the assessed psychosocial interventions did not appear to have a significant impact on psychological stress or well-being, but again a relationship was observed between younger age and better outcomes. 160 Outcomes of these interventions may also depend largely on the age of the individual. While prior studies of psychosocial interventions demonstrate some degree of efficacy in older adults with vision loss, and particularly AMD, 161 meta-analytic findings indicate that improvements are less robust in elderly samples. 160 Related to this finding, risk and protective factors for mental health problems in older adults may be different from those of younger people, 29 and therefore treatment may need to be adapted to fit the individual needs of the consumer. 160 One issue relevant to this point is that with increasing age there is more likely to be failure of other bodily systems, and other situations (eg, loss of a spouse) that promote depression. Therefore, interventions that are associated with a significant reduction in depression in younger patients may appear to have reduced benefit in older patients, even if the absolute level of change is the same in both populations (owing to increased baseline depression levels in the latter group). Finally, the relatively high rates of treatment non-adherence and attrition reported in some studies 41 , 137 , 148 is problematic and limits the interpretation of results, especially their generalizability. In short, overall, there is evidence of mild-to-moderate effects of existing approaches for treating mental health problems in people with visual impairment broadly. Further efforts are needed to develop novel interventions that can be applied to a wider range of individuals with vision impairment, and to develop interventions for people with more severe depression and/or who are nonadherent with recommended treatment.
Vision loss affects all aspects of one’s life. The findings reviewed indicate that mental health problems are a significant burden for many people with vision impairment., 9–11 However, despite the widespread prevalence of these issues, screening and treatment remain inadequate. Better outcomes may be achieved if several changes are made. First, more rigorous evaluation of current treatment approaches is warranted. In addition to measuring long-term outcomes, treatment efficacy needs to be tested in a broader sample of people with vision impairment, including children and individuals with complete blindness. More work is also needed to identify mechanisms of change (eg, reductions in vision-specific distress, 12 maintaining valued activities, 144 recovery of self-esteem, increased hope for the future, etc.). 162 Related to this, in addition to screening for level of issues such as depression and anxiety, screening should adequately capture the patient’s stage of emotional adjustment to vision loss 162 so that the treatment approach matches the patient’s perspective on his/her condition. In addition to targeting mental health problems, it is critical to focus on poor adherence, especially for people who could be receiving an effective intervention. Dismantling studies are also needed to identify important treatment components, as was done in a study of AMD when the effects of a single cognitive-behavioral component, behavioral activation, was examined in combination with vision rehabilitation, and results were positive. 153 Additionally, client characteristics that may influence treatment outcomes, such as age, 89 , 90 , 120 severity and duration of vision loss, 19 , 20 , 22 , 24 and prognosis of the disease 18 , 94 need to be recognized. It is also important that these factors, and other potentially confounding variables (eg, functioning, social support, psychiatric history, family history of eye disease), are controlled for in studies of treatment effectiveness. Finally, at least some subpopulations (eg, AMD patients with low income and with psychological denial of disability) may require a greater focus on issues that interfere with treatment adherence, as poor adherence may affect outcomes more than the disease in cases where effective treatments are available.
In order to improve access to care, structural changes may be required. This may include integrating services, such as behavioral health and ophthalmology, or even general healthcare given high rates of medical comorbidity in this population. 31 , 86 Relatedly, routine screening for mental health problems in eye care settings may be beneficial, and has high acceptability among patients (ie, considered a “good idea”). 39 A discussion between patients and their providers regarding the relationship between visual impairment and mental health, and factors that may increase risk for mental health problems, may improve access and engagement in mental health services. Furthermore, providing information and educating patients and their families on the potential effects of vision loss on functioning over time may facilitate the development of self-supportive strategies that allow patients to better manage future challenges. An expansion of current treatment options is also needed in order to serve a wider range of individuals with vision loss. Though data are limited, there is some evidence that peer support groups for people with vision impairment have positive effects on mental health, 163 and in qualitative studies patients report benefiting from their peers in a multitude of ways (eg, providing role models of success, allowing comparison with those more unfortunate). 164 In addition, delivering therapy by phone 148 or through mobile applications may increase treatment accessibility, particularly among individuals with mild or moderate symptom levels that may be undetected by general health providers. Further introduction of established mental health interventions to visually impaired populations is also essential, especially regarding treatments that have demonstrated efficacy in general depression populations, as mood symptoms may be especially problematic in people with vision impairment. 9 , 11 For instance, acceptance and commitment therapy (ACT) is a “third wave” form of cognitive therapy that encourages acceptance of events (vs experiential avoidance) and behavior change that is guided by goals and values, and has demonstrated superiority over other treatments in improving depression, anxiety, and other mental health problems among people with physical health conditions, 165 such as chronic pain. 166 In older adults with vision impairment, a relationship between lower acceptance of vision loss and subthreshold depression has been reported 126 and avoidant coping has been identified as a unique predictor of both vision-specific distress and depressive symptoms. 77 Thus, an intervention aimed at enhancing psychological adjustment and coping, such as ACT, may have a positive effect in people with vision loss. In summary, implementing a variety of changes to improve the detection and treatment of mental health problems in people with vision impairment may lessen health inequity and improve outcomes in this population.
Vision impairment has a substantial personal and global impact. 4 , 5 , 31 Besides high rates of physical comorbidity, people with visual impairments are at risk for poor mental health outcomes. 9–11 Importantly, approximately 68% of vision impairment is avoidable. 167 While blindness as a result of age-related disease (eg, AMD, diabetic retinopathy, glaucoma) is not reversible at this point, many impairments can be corrected or altogether avoided 131 with better attention to eye health, and doing so should prevent development of some mental health problems. However, better screening for mental health changes and greater availability of effective treatments, and of adequately trained (with regard to understand the psychological consequences of vision loss) mental health professionals, are necessary as well. It is also critical to increase our understanding of the range of psychological and psychosocial effects associated with visual disability (and anticipation of it) and the mechanisms that contribute to the onset and maintenance of mental health problems in this population. While it is important to address both the emotional and practical needs of people with visual impairment, historically, mental health concerns have been largely overlooked in these individuals. Proper attention to mental health issues is likely to be a complex endeavor, however, as it requires widespread screening, careful attention to the patient’s stage of emotional adjustment to living with vision loss, development of novel interventions, availability of trained practitioners, and addressing health disparities related to socio-economic status.
The authors report no conflicts of interest in this work.
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Purpose: To describe a systematic review of population-based prevalence studies of visual impairment (VI) and blindness worldwide over the past 32 years that informs the Global Burden of Diseases, Injuries and Risk Factors Study.
Methods: A systematic review (Stage 1) of medical literature from 1 January 1980 to 31 January 2012 identified indexed articles containing data on incidence, prevalence and causes of blindness and VI. Only cross-sectional population-based representative studies were selected from which to extract data for a database of age- and sex-specific data of prevalence of four distance and one near vision loss categories (presenting and best-corrected). Unpublished data and data from studies using rapid assessment methodology were later added (Stage 2).
Results: Stage 1 identified 14,908 references, of which 204 articles met the inclusion criteria. Stage 2 added unpublished data from 44 rapid assessment studies and four other surveys. This resulted in a final dataset of 252 articles of 243 studies, of which 238 (98%) reported distance vision loss categories. A total of 37 studies of the final dataset reported prevalence of mild VI and four reported near VI.
Conclusion: We report a comprehensive systematic review of over 30 years of VI/blindness studies. While there has been an increase in population-based studies conducted in the 2000s compared to previous decades, there is limited information from certain regions (eg, Central Africa and Central and Eastern Europe, and the Caribbean and Latin America), and younger age groups, and minimal data regarding prevalence of near vision and mild distance VI.
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