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Effect of Depression on Vision Function in Age-Related Macular Degeneration
Barry W. Rovner, MD;
Robin J. Casten, PhD;
William S. Tasman, MD
Arch Ophthalmol. 2002;120:1041-1044.
ABSTRACT
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Objectives To report the prevalence rate of depression in older patients with recent
vision loss due to age-related macular degeneration (AMD) and to describe
the effect of depression on self-reported vision function during 6 months.
Methods Prospective cohort study of 51 older patients with recent-onset bilateral
AMD attending the Retina Clinic of Wills Eye Hospital, Philadelphia, Pa. Main
outcome measures included the Center for Epidemiological Studies Depression
Scale, visual acuity, Functional Vision Screening Questionnaire, Chronic Disease
Score, and Community Disability Scale.
Results Seventeen patients (33%) were depressed at baseline and had worse visual
acuity (P = .04) and greater levels of vision-specific
(P = .03) and general (P
= .002) physical disability than nondepressed patients. The correlations of
Center for Epidemiological Studies Depression Scale score with visual acuity
and visual-specific disability, however, were not significant after controlling
for general physical disability. An increase in depressive symptoms over time
predicted decline in self-reported vision function independent of changes
in visual acuity or medical status (P<.05).
Conclusions The prevalence and disabling effects of depression in older patients
with AMD are substantial. Recognizing that depression is a treatable disorder
that exacerbates the effects of AMD will lead to improved outcomes. Innovative
interventions to prevent or treat depression in specialty eye clinics are
possible.
INTRODUCTION
THE PREVALENCE and disabling effects of age-related macular degeneration
(AMD) are increasing as the population ages.1
Williams,2 Mangione,3
and Scott4 et al demonstrated that AMD causes
high levels of emotional distress and reduced quality of life. However, whereas
the first 2 studies noted weak, nonsignificant relationships between visual
acuity and quality-of-life measures, the latter found that worse visual acuity
was associated with emotional distress.2-4
Brody et al5 found high rates of depression
and significant correlations between depression and vision-specific and general
disability but not with visual acuity.5 We
have previously found that the relationship between visual acuity and depression
is mediated by the loss of valued, discretionary activities.6
These studies show that, although AMD substantially disrupts the quality of
patients' lives, its disabling effects and not its severity per se predict
depression.
The studies cited above have been cross sectional, however, and are
confounded by the reciprocal relationships between depression and disability
(ie, disability leads to depression, depression exacerbates disability). There
have been no longitudinal studies investigating changes in visual acuity,
disability, and depression to clarify these relationships, to our knowledge.
In this prospective study, we report the prevalence rate of depression in
older patients with recent-onset bilateral AMD and describe the longitudinal
relationships between changes in visual acuity, vision function, and depression
in these patients.
PATIENTS AND METHODS
We screened consecutive patients at the Wills Eye Hospital Retina Service,
Philadelphia, Pa, to identify those with preexisting AMD in one eye with visual
acuity worse than 20/70, who had vision loss in the second eye due to exudative
AMD within the preceding 6 weeks resulting in visual acuity worse than 20/70.
We chose these criteria to identify subjects with sufficiently impaired vision
to cause functional limitations and recent onset of bilateral vision loss.
Additional inclusion criteria were age greater than 64 years and residence
within 25 miles of Wills Eye Hospital. We excluded cognitively impaired subjects
(eg, 3 or more errors on the Kahn-Goldfarb Mental Status Questionnaire).7
Potential subjects (N = 109) were screened from January 1, 1998, to
July 31, 1998, until the planned enrollment of 51 subjects was completed.
We based this sample size on the previously reported strong correlation (r = 0.44; confidence interval, 0.19-0.64) of the Geriatric
Depression Scale with general function in visually impaired subjects.8 With the proposed sample of 51, the study has 92.9%
power ( = .05, 2-tailed) to detect a moderate correlation between depression
and disability. Sixty-four subjects met the inclusion criteria and 51 (79.7%)
agreed to the in-home clinical interview. There were no differences in demographic
or vision characteristics between those who refused and subjects who were
enrolled. We reinterviewed 46 subjects (90% of those enrolled) 6 months later.
The Thomas Jefferson University institutional review board approved this investigation;
all subjects provided informed signed consent. The Batelle Center for Public
Health Research and Evaluation, Baltimore, Md, conducted the in-home interviews.
Two graduate-level professional surveyors assessed depressive symptoms and
visual and physical disability. Ophthalmologic diagnoses and distance acuity
were ascertained from subjects' Wills Eye Hospital records.
We evaluated depression by means of the Center for Epidemiological Studies–Depression
(CES-D) Scale.9 This instrument contains 20
items that assess the severity and frequency of depressive symptoms during
the past week. The CES-D scores range from 0 to 60; higher scores indicate
more severe depressive symptoms. A score of 16 or higher has high sensitivity
and specificity rates for identifying subjects with depressive disorder.10 Patients with CES-D scores greater than 16 were categorized
as depressed in this study.
Baseline visual acuity (best-corrected distance visual acuity in the
better eye) was measured at Wills Eye Hospital by means of the Snellen eye
chart. Visual acuity at 6 months was obtained from Wills Eye Hospital and
community ophthalmologists' records. Distance acuity was transformed into
the logarithm of the minimum angle of resolution (logMAR), which converts
visual fractions to a metric value more easily fitted to statistical analyses.
We used the Chronic Disease Score (CDS) to provide an objective measure
of medical morbidity derived from a weighted sum of medications taken for
chronic disease.11 Clark et al12
validated the CDS on more than 250 000 managed care enrollees and found
that it predicts health care utilization, costs, hospitalization, and mortality.12 The CDS is scored as projected yearly total health
care costs in dollars.
We assessed vision-related disability by means of the Functional Vision
Screening Questionnaire, which consists of 15 self-rated yes-no items that
rate performance on vision-related tasks (eg, watching television, reading
newsprint, recognizing faces, driving). Scores range from 0 to 15, with higher
scores indicating greater disability. A score of 9 has sensitivity of 0.72
and specificity of 0.94 to detect patients with a corrected distance acuity
of 20/70 or worse.13 The term vision function refers to self-rated Functional Vision Screening Questionnaire
scores.
We used the Community Disability Scale to assess activities of daily
living, instrumental activities of daily living, and mobility.14
This 28-item instrument was used in the East Baltimore Mental Health Epidemiologic
Catchment Survey on 175 000 adults. Higher scores indicate greater disability.
Initial analyses consisted of comparing subjects who were and were not
depressed at baseline by means of 1-way analyses of variance and  2 for linear and categorical variables, respectively. A multiple regression
analysis was used to delineate correlates of baseline CES-D score. Six-month
change in vision function was evaluated with a separate multiple regression.
RESULTS
Seventeen patients (33%; 95% confidence interval [CI], 19.9-47.0) were
depressed (CES-D score >16) at baseline (ie, 6 weeks after vision loss in
the second eye). Table 1 compares
their demographic and clinical characteristics with those of the 34 nondepressed
patients. Depressed subjects had worse visual acuity and greater levels of
both vision-specific and general physical disability than nondepressed patients
but were otherwise comparable in severity of comorbid medical disorders and
demographic characteristics.
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Table 1. Comparison of 17 Depressed and 34 Nondepressed Subjects on
Baseline Characteristics*
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Depression scores were significantly correlated with vision-specific
disability (r = 0.31; 95% CI, 0.04-0.54), general
physical disability (r = 0.57; 95% CI, 0.36-0.93),
and logMAR (r = 0.34; 95% CI, 0.07-0.56) (all P<.05) but not with CDS (r
= -0.04). The LogMAR was significantly correlated with vision function
(r = 0.41; 95% CI, 0.15-0.72; P<.003) but not with general function (P
= .9). Table 2 shows the results
of a multiple regression analysis with CES-D score as the dependent measure.
Vision function, general function, visual acuity, and CDS were the independent
measures and were entered on one block. Only general function was significant
(P<.001), indicating that vision-specific disability
and acuity were not uniquely related to depression after controlling for physical
disability. We found identical results in models including either vision-specific
disability or visual acuity but not both simultaneously.
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Table 2. Multiple Linear Regression Predicting CES-D (n = 50)*
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There were complete 6-month follow-up data on 40 (78%) of the 51 subjects.
We compared the 40 subjects with complete data with the 11 without and found
no differences in demographic characteristics, function (both vision-specific
and general), or visual acuity. Those without complete data, however, had
higher mean CES-D scores at baseline (mean, 17.3; SD, 8.8) than subjects with
complete data (mean, 10.5; SD, 7.7; P = .02). Other
research confirms that older subjects lost to follow-up in longitudinal studies
tend to be more depressed and less physically healthy.15
This suggests that our results might be biased toward more functional patients
with AMD and underestimate the psychological needs of patients with AMD. Of
the 13 patients with depression at baseline on whom follow-up data were available,
7 remained depressed at 6 months. The 6 "remitted" patients continued to have
depressive symptoms (mean CES-D score, 10.8; SD, 3.8), however, exceeding
that reported in older persons in the community (mean CES-D score, 8.06; SE,
0.19).16 One depressed subject was treated
for depression at baseline and 2 were treated at 6 months.
To examine change over time, we performed a series of paired t tests comparing baseline with 6-month data for visual acuity, CES-D
score, vision function, general function, and CDS. There were significant
declines in vision function (P = .005) and general
function (P = .01) but no significant changes in
visual acuity (P = .24), CES-D (P = .26), or CDS (P = .98). To assess change
in vision function in relation to changes in CES-D and visual acuity, we first
examined the zero-order correlations between the change scores. Change in
vision function was significantly correlated with change in CES-D (r = 0.32; P = .03) but not with change in
logMAR (r = -0.04; P
= .83). We then performed a hierarchical linear regression to determine whether
the significant correlation between change in vision function and change in
CES-D was sustained when baseline CES-D score and change in visual acuity
were controlled. The dependent variable was change in vision function, and
both baseline visual acuity and change in acuity were entered on the first
step. Baseline CES-D scores and change in CES-D were entered on the second
step. As indicated in Table 3,
only change in CES-D (worsening depression) was significantly related to change
(decline) in vision function. These data suggest that the process of worsening
depressive symptoms, rather than their absolute level at baseline or change
in acuity over 6 months, is related to vision function.
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Table 3. Multiple Regression Predicting in Vision Function (n = 40)*
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COMMENT
This investigation reports the prevalence and impact of depression in
this particular population of older persons with bilateral AMD. Its strengths
are its prospective design and systematic ascertainment, assessment, and follow-up
of subjects whose affective, medical, and functional characteristics were
carefully characterized by means of reliable and valid instruments. The study's
limitations are its small size, limited generalizability given the specific
inclusion criteria and attrition (which may underestimate the effects of depression),
reliance on visual acuity as the sole measure of AMD severity, and the use
of a self-reported vision function measure less well validated than the National
Eye Institute Visual Function Questionnaire or Activities of Daily Vision
Scale.17-18 In fact, our use of
a self-report rather than a performance-based measure of vision function cannot
control for the potentially confounding effect of depression on self-ratings
of function.19
We found high rates of depression at 6 weeks after vision loss in the
second eye. The 33% rate exceeds the 16% rate reported in 2 community population
studies and is comparable with the 35.2% rate reported in primary care with
the use of the same method to diagnose depression.10, 19-20
It agrees with Brody and coworkers' report5
of a 32.5% prevalence rate of depressive disorder in patients with advanced
AMD. Because only 1 subject in this study was receiving treatment for depression
at baseline, we suspect that the rate of preexisting depression (before vision
loss in the second eye) was extremely low.
Depressed patients had more general and vision-specific disability than
nondepressed patients and slightly worse visual acuity, although the correlations
between CES-D score and both vision-specific disability and visual acuity
were not significant after controlling for general disability. These findings
agree with those of others reporting weak or nonsignificant relationships
between visual acuity and depression, and others reporting reciprocal relationships
between disability and depression in older patients with chronic medical diseases.2-5,21-22
However, because many nonophthalmologic diseases (eg, cardiovascular disease
and cancer) share symptoms with depression (eg, fatigue and anorexia), disentangling
their effect on disability has been difficult. Age-related macular degeneration
provides a unique disease model to examine these interrelationships because
it shares no symptoms with depression. Our longitudinal data suggest that
as depressive symptoms increase over time, there is a corresponding decline
in vision function occurring independently of change in visual acuity. We
found a similar effect when depression was analyzed as the categorical diagnosis
of major depression.23 The current report extends
that finding by demonstrating that vision function declines in patients whose
depression symptoms increase, regardless of whether they meet criteria for
major depression. The psychological and somatic symptoms of depression probably
account for its adverse effect on vision function. Discouragement and helplessness
drain inner resolve and resiliency, and anergia, poor appetite, and sleep
impair effortful behaviors.
Ophthalmologists are well aware of the emotional consequences of AMD
and have been as frustrated in their efforts to respond to depression as they
are to restore vision. Unfortunately, many obstacles prevent them from treating
depression, such as resource and time constraints and lack of familiarity
with treatment indications and psychotropic medications. As a result, depression
remains an untreated source of excess disability in many patients. Our findings
attest to these disabling effects of depression but also suggest that interventions
may be helpful. Recognizing that depression is not simply an understandable
consequence of vision loss but rather a distinct, treatable disorder is a
necessary first step. Second, ophthalmologists can encourage patients and
their families to seek psychiatric care for demoralization and hopelessness,
especially if these symptoms persist over time. Third, innovative interventions
to prevent or treat depression in specialty eye clinics are possible. We are
currently evaluating the efficacy of a psychosocial intervention to prevent
depression in older persons with AMD in a randomized, controlled clinical
trial funded by the National Institute of Mental Health. Brody et al24 already demonstrated the efficacy of a brief, behavioral
group intervention to improve mood, self-efficacy, and use of vision aids
in a similar population. Interventions such as these, as well as others that
include education about AMD, increased access to community services, low-vision
rehabilitation, support groups, home modifications, and treatment of depression,
may ultimately prevent depression and enhance functioning and quality of life.
Until treatments to restore vision are available, these approaches provide
optimal care to patients with AMD.
AUTHOR INFORMATION
Submitted for publication December 11, 2001; final revision received
April 15, 2002; accepted April 24, 2002.
This study was supported by grant MH61331 from the National Institute
of Mental Health, Bethesda, Md, and a charitable grant from The Ralston House,
Philadelphia, Pa.
We thank Oneita M. Harmon for preparation of the manuscript and Mitchell
Feinman, MD, for ascertainment of the sample.
Corresponding author and reprints: Barry W. Rovner, MD, Geriatric
Psychiatry, Wills Eye Hospital, 900 Walnut St, Eighth Floor, Philadelphia,
PA 19107 (e-mail: Barry.Rovner{at}mail.tju.edu).
From the Departments of Psychiatry and Human Behavior (Drs Rovner and
Casten) and Ophthalmology (Dr Tasman), Jefferson Medical College, Thomas Jefferson
University, and Wills Eye Hospital (Dr Tasman), Philadelphia, Pa.
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