DEPRESSION AND AMD

Active psychological therapeutic intervention can provide significant benefits in patients with vision loss from bilateral age-related macular degeneration (AMD), a new study suggests. 
Published online in the journal Ophthalmology, the Low VIsion Depression Prevention TriAL (VITAL) study highlights the high risk of depression in patients with AMD and should reinforce for ophthalmologists the importance of a holistic approach to providing services for these individuals.
“Although retina specialists often focus on vision as the outcome of interest in our patients, this study reminds us that people value vision because it allows them to maintain independence and continue to enjoy certain activities. To optimise care for patients with AMD, we need to think about the patient as a whole rather than looking only at vision,” said Allen C Ho MD, director of retina research Wills Eye Hospital and professor of ophthalmology Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, US.
Barry W Rovner MD, is principal investigator for VITAL and professor of neurology and psychiatry, Sidney Kimmel Medical College of Thomas Jefferson University. He told EuroTimes that the study is important for getting ophthalmologists to recognise depression in patients with AMD as a preventable and treatable problem. “Depression in older patients who have lost vision is commonly seen as an understandable reaction, but explaining the depression away in that manner is a nihilistic perception that fails to address the problem. The VITAL study helps to underscore that depression is a medical problem that deserves our full medical and psychological attention,” he said.
The study included 188 patients with vision loss from AMD (BCVA <20/70 in the better eye), sub-syndromal depressive symptoms identified using the Patient Health Questionnaire-9 and moderate difficulty performing a valued vision-dependent activity. All patients initially received low vision rehabilitation services and then were randomised to supportive therapy delivered by a masters-level therapist, or behaviour activation (BA) therapy delivered by an occupational therapist. 
Each approach involved six in-home one-hour sessions over an eight-week period. Supportive therapy is a psychological treatment designed to provide emotional support and controls for attention. BA addresses both depression and functional deficits of vision loss and is a structured, individualised treatment plan incorporating environmental modifications and action plans designed to address the specific barriers a patient faces in accomplishing valued personal and functional goals. 
“The guiding concept underlying behaviour activation intervention is the link between action, mood and mastery,” said Dr Rovner. “It recognises that when people have greater confidence in their abilities, they can do more and will feel better.”
Progression to major or minor depression (DSM-IV criteria) after four months was evaluated as the primary outcome. BA cut the rate by half. Progression to severe depression occurred in 23.4 per cent of the supportive therapy patients, which is consistent with published data on the prevalence of depression among patients with AMD, but in only 12.6 per cent of patients receiving BA therapy. Follow-up is ongoing and a future analysis will investigate whether the benefit of BA observed after four months is sustained at one year. 
Findings from other assessments showed patients who received BA demonstrated greater improvements in near functional vision than the control group and remained more socially engaged.
An effectiveness analysis showed that nine patients would need to be treated to prevent one additional case of depression. Considering the subgroup of patients with worse baseline vision (<20/100 in the better eye), the benefit of BA was even stronger as the number needed to treat (NNT) for that cohort was only five. To put some perspective onto those numbers, the investigators noted the NNT is 38 for intensive glycolic control over four years to prevent one case of clinically important diabetic retinopathy.
Dr Rovner also pointed out that while there are costs involved in delivering the integrated low vision and BA treatment, they are relatively small weighed against the economic and other burdens of depression and the sequelae of an accident and injury that results because of low vision.

Allen C Ho: acho@att.net
Barry W Rovner: barry.rovner@jefferson.edu