Edith E. Holloway

Integrated Depression Management: A Proposed Trial of a New Model of Care in a Low Vision Rehabilitation Setting

Abstract Purpose: Depression is a common problem among people with visual impairment and contributes to functional decline. This article presents a study protocol to evaluate a new model of care for those patients with depressive symptoms in which psychological treatment is integrated into low vision rehabilitation services. Low vision staff will be trained to deliver “problem solving therapy for primary care” (PST-PC), an effective psychological treatment developed specifically for delivery by non-mental health care staff. PST-PC is delivered in 8 weekly telephone sessions of 30–45 minutes duration and 4 monthly maintenance sessions. We predict this new integrated model of care will significantly reduce depressive symptoms and improve the quality of life for people with visual impairment. Methods and Design: A randomized controlled trial of PST-PC will be implemented nationally across low vision rehabilitation services provided by Vision Australia. Clients who screen positive for depressive symptoms and meet study criteria will be randomized to receive PST-PC or usual care, consisting of a referral to their general practitioner for more detailed assessment and treatment. Outcome measures include depressive symptoms and behaviors, quality of life, coping and psychological adjustment to visual impairment. Masked assessments will take place pre- and post-intervention as well as at 6- and 12-month follow-up. Conclusion: We anticipate that this innovative service delivery model will lead to sustained improvements in clients’ quality of life in a cost effective manner and provide an innovative service delivery model suitable for other health care areas in which depression is co-morbid.

Identifying distinct risk factors for vision-specific distress and depressive symptoms in people with vision impairment.

PURPOSE To determine the relative importance and associated risk factors of vision-specific distress and depressive symptoms in people with visual impairments. METHODS In this cross-sectional study, 162 adult patients with visual acuity less than 6/12 were interviewed using telephone-administered questionnaires. Vision-specific distress was assessed with the emotional well-being scale of the Impact of Vision Impairment Questionnaire. Depressive symptoms were assessed with the Patient Health Questionnaire-9. Other measures including vision-specific functioning, coping, and social support were also assessed. Multiple regression and commonality analysis were used to determine the relative contribution of factors explaining variance in vision-specific distress and depressive symptoms. RESULTS Vision-specific distress and depressive symptoms were strongly associated. Vision-specific functioning (βs = 0.47, P < 0.001), avoidant coping (βs = -0.32, P < 0.001), social coping efficacy (βs = -0.17, P = 0.001), and depressive symptoms (βs = 0.18, P = 0.006) were significant determinants of vision-specific distress. Vision-specific functioning accounted for 37.7% of the unique variance in this model. Vision-specific distress was an important risk factor for depression, accounting for 36.6% of the unique variance in depressive symptoms. CONCLUSIONS Vision-specific distress is related to a persons ability to manage the practical and social challenges of vision impairment. Further work is required to distinguish vision-specific distress and depression and to examine what interventions are best to target vision-specific distress.

Do problem-solving interventions improve psychosocial outcomes in vision impaired adults: A systematic review and meta-analysis☆

OBJECTIVE To evaluate the effectiveness of problem-solving interventions on psychosocial outcomes in vision impaired adults. METHODS A systematic search of randomised controlled trials (RCTs), published between 1990 and 2013, that investigated the impact of problem-solving interventions on depressive symptoms, emotional distress, quality of life (QoL) and functioning was conducted. Two reviewers independently selected and appraised study quality. Data permitting, intervention effects were statistically pooled and meta-analyses were performed, otherwise summarised descriptively. RESULTS Eleven studies (reporting on eight trials) met inclusion criteria. Pooled analysis showed problem-solving interventions improved vision-related functioning (standardised mean change [SMC]: 0.15; 95% CI: 0.04-0.27) and emotional distress (SMC: -0.36; 95% CI: -0.54 to -0.19). There was no evidence to support improvements in depressive symptoms (SMC: -0.27, 95% CI: -0.66 to 0.12) and insufficient evidence to determine the effectiveness of problem-solving interventions on QoL. CONCLUSION The small number of well-designed studies and narrow inclusion criteria limit the conclusions drawn from this review. However, problem-solving skills may be important for nurturing daily functioning and reducing emotional distress for adults with vision impairment. PRACTICE IMPLICATIONS Given the empirical support for the importance of effective problem-solving skills in managing chronic illness, more well-designed RCTs are needed with diverse vision impaired samples.

Depression screening among older adults attending low-vision rehabilitation and eye-care services: Characteristics of those who screen positive and client acceptability of screening.

To investigate characteristics associated with screening positive for depressive symptoms among older adults accessing low‐vision rehabilitation and eye‐care services and to determine client acceptability of depression screening using the Patient Health Questionnaire‐2 (PHQ‐2) in these settings.

Help seeking among vision-impaired adults referred to their GP for depressive symptoms: patient characteristics and outcomes associated with referral uptake

Adults with vision impairment commonly experience depression; however, depression often remains undetected and therefore untreated in this group. Using a prospective longitudinal design, the aim of this study was to determine the rate of uptake for a referral to a general practitioner (GP), in vision-impaired adults, who were screened for depression in low vision rehabilitation and eye-care settings. Fifty-seven vision-impaired adults (aged ≥ 18 years) were recruited from low vision rehabilitation centres across Australia and the Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, between June 2010 and May 2012. Participants screened positive for depressive symptoms and were referred to their GP for follow up. Telephone assessments took place at baseline, 3 and 6 months to determine uptake of a GP referral and changes in depressive symptoms over 6 months. Forty-six per cent of participants followed through with the GP referral. A desire for emotional support and stigma towards seeking support from a psychologist were significantly associated with uptake (both P < 0.05). GPs were more likely to recommend anti-depressant medication compared with a psychologist consultation (69% v. 54%) and patients themselves were more likely to take anti-depressant medication (94% v. 14% who saw a psychologist). Depressive symptoms decreased significantly over 6 months for those who followed through with a GP referral (baseline M = 10.04, s.d. = 5.76 v. 6-months M = 6.20, s.d. = 3.38; z = -2.26, P = 0.02) but not for those who did not use the GP referral (z = -1.92, P = 0.55). This method of referral to a GP following depression screening may provide an effective pathway to detect and manage depression in vision-impaired adults.

Screening for depression: integrating training into the professional development programme for low vision rehabilitation staff

Background:  To describe the integration of depression screening training into the professional development programme for low vision rehabilitation staff and report on staff evaluation of this training.

Rehabilitation staff perspectives on training for problem-solving therapy for primary care in a low vision service

Vision rehabilitation staff were trained to deliver problem-solving therapy for primary care (PST-PC) over the telephone to adults with depressive symptoms and low vision. Training was a 2-day workshop, completion of training cases, and assessment of treatment fidelity. Staff perspectives of training and challenges in PST-PC delivery were explored. Telephone-administered semi-structured interviews were conducted pre- and post-workshop and following PST-PC competency. In all, 14 staff (mean age = 47.64 years, SD = 12.68 years, 93% females) achieved competency and 6 withdrew. Results showed an increased understanding of PST-PC from pre- to post-workshop (Z = −2.71, p = .007) and pre-workshop to post-competency (Z = −3.09, p = .002). A high level of satisfaction with training was reported. Staff challenges included the clients’ ability to define problems and brainstorm solutions. Training enabled staff to competently deliver PST-PC and may serve as a model for integrating depression care into vision rehabilitation services recommended by international guidelines.

The Prevalence and Determinants of Desire for and Use of Psychological Support in Patients With Low Vision.

PurposeThe objective of this study was to identify the prevalence and determinants of desire for and use of psychological support in patients with low vision. DesignThe study was cross-sectional, utilizing telephone-administered interviews. MethodsPatients were recruited from Vision Australia and the Royal Victorian Eye and Ear Hospital with visual acuity of less than 6/12 in the better eye. Measures were the 9-item Patient Health Questionnaire, Stigma Scale for Receiving Psychological Help, Brief Illness Perception Questionnaire, and Impact of Vision Impairment Questionnaire. ResultsOf the total 161 participants (mean ± SD, 69.94 ± 15.76 years; 67% female), 63% desired psychological support, but only 20% reported ever receiving this. Higher levels of depressive symptoms and poorer coping in relation to vision impairment were significantly associated with desire for psychological support. Younger age, experience/s of depression, and beliefs about depression and its treatment were associated with use of professional support. ConclusionsMany patients with low vision desired psychological support but were not receiving this, suggesting barriers to receipt of care. This highlights the need for early screening of emotional difficulties, depression education, and easy access to psychological support within low vision services.

Illness Cognitions and Coping Self-Efficacy in Depression Among Persons With Low Vision.

PURPOSE To investigate the mediating role of coping self-efficacy (CSE) between two types of illness cognitions (i.e., acceptance and helplessness) and depressive symptoms in persons with low vision. METHODS This was a single-group, cross-sectional study. Patients with visual acuity < 6/12 in the better eye and at least minimal depressive symptoms (≥5 on the Patient Health Questionnaire-9 [PHQ-9]) were recruited from vision rehabilitation services and participated in telephone-administered structured interviews at one time point. Measures were the PHQ-9, CSE Scale, and Illness Cognition Questionnaire. Structural equation modeling (SEM) devised the causal flow of illness cognitions and their observed indirect effects on depressive symptoms via the CSE mediators: problem focused, emotion focused, and social support. RESULTS The study comprised 163 patients (mean age 62 years; 61% female), most with age-related macular degeneration (26%) and moderate vision impairment (44%, <6/18-6/60). Structural equation modeling indices indicated a perfect fit (χ2 < 0.001, P = 1.00), accounting for 55% of the variance in depressive symptoms. Lower levels of acceptance and higher levels of helplessness illness cognitions were associated with lower self-efficacy in problem-focused coping (β = 0.38, P < 0.001, β = -0.28, P < 0.01, respectively), which in turn was associated with greater depressive symptom severity (β = -0.54, P < 0.001). CONCLUSIONS Lack of acceptance and greater helplessness relating to low vision led to a lack of perceived capability to engage in problem-focused coping, which in turn promoted depressive symptoms. Third-wave cognitive-behavioral treatments that focus on acceptance may be efficacious in this population.

Delivering problem-solving treatment in low-vision rehabilitation: A pilot feasibility study.

Purpose: To explore the feasibility and preliminary effectiveness of Problem-Solving Treatment for Primary Care (PST-PC) delivered by low-vision rehabilitation (LVR) practitioners to adult clients with depressive symptoms. Design/Method: A single-group pre/postintervention study. Eighteen adult LVR clients with depressive symptoms (Patient Health Questionnaire–9 [PHQ-9] score of ≥5) received 6–8 weekly telephone sessions of PST-PC delivered by expertly trained practitioners (n = 14). Feasibility was determined via participating client and practitioner recruitment and intervention retention rates. Depressive symptoms (PHQ-9), health-related quality of life (HRQoL; Assessment of QoL Instrument–7D), and confidence in one’s ability to cope using problem-solving strategies (Coping Self-Efficacy Scale) were assessed using pre/posttelephone assessments. Results: Participating client recruitment and retention rates were 71% and 40%, respectively. Seventy percent of practitioners completed supervised training in PST-PC and demonstrated satisfactory levels of fidelity and competency. Postintervention, we observed a 53% improvement in depressive symptoms (p < .001), a 23% improvement in HRQoL (p = .001), and an 18% improvement in participants’ confidence to use problem-focused coping strategies (p = .001). Conclusions: Telephone–PST-PC delivered by a trained LVR practitioner may be an effective intervention for clients of LVR services who exhibit depressive symptoms. A randomized controlled trial is now needed to confirm these preliminary findings and establish longer-term effectiveness.