With aging comes a host of associated problems. One of them is age-related macular degeneration (AMD), the primary reason for vision loss among people older than 50. Progressive decline in vision can often leave the patient confused, and depression is a major risk in such cases.

In order to reduce this risk, a new study has suggested a novel intervention, which combines low vision therapy with psychological rehabilitation. The study, called Low Vision Depression Prevention Trial (VITAL), funded by the National Eye Institute (NEI), part of the National Institutes of Health, estimates to cut the risk of depression by 50 percent.

"Our results emphasize the high risk of depression from AMD, and the benefits of multi-disciplinary treatment that bridges primary eye care, psychiatry, psychology, and rehabilitation,” said Dr. Barry Rovner, a professor of psychiatry and neurology at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia. The findings have been published in the journal, Ophthalmology.

AMD is the leading cause of blindness in older Americans and affects more than 10 million people. As we grow older, the macula, which is a small spot near the center of the retina and is needed for good vision, starts deteriorating. When the macula gets damaged, our vision starts appearing blurry, distorted, or dark.

If AMD affects both eyes, it is called bilateral AMD. While age is the major risk factor for AMD, excessive smoking and family history also contribute. AMD is progressive and leaves the affected person incapable of doing day-to-day chores like driving, reading, writing, watching television, and cooking.

An inability to pursue valued and even the simplest of activities, often leaves AMD-affected people depressed. Studies have found that as many as one-third of people with bilateral AMD develop clinical depression. "The depression is a response to disability, so we reasoned an effective treatment would be to reduce the disability through rehabilitation," Rovner said.

In VITAL, he led a team of psychologists, ophthalmologists, optometrists, and occupational therapists to test an approach called behavior activation. Dr. Robin Casten, study co-author, says that maintaining an active social life is imperative to this approach. "Behavior activation involves helping people to focus on activities they enjoy, to recognize that loss of those activities can lead to depression, and to re-engage in those activities,” she said in a press release.

The trial recruited 188 participants with an average age of 84 years with bilateral AMD from an ophthalmology practice affiliated with Wills Eye Hospital in Philadelphia. Seventy percent were women and almost half of them lived alone. All had a best-corrected vision of less than 20/70 (20/20 vision is considered normal while a 20/70 vision means the person sees an object from 20 feet away as clearly as a person with normal vision sees it at 70 feet away.)

Each participant exhibited mild depressive symptoms, which could develop into clinical depression based on a nine-item depression subtest of the Patient Health Questionnaire, or PHQ-9.

"We felt that this trial addressed an important need. Ophthalmologists have many tools at the ready for treating AMD, and we are continuing to forge links with other health care providers to effectively treat the whole patient," said Dr. Allen C. Ho, director of the Clinical Retina Research Unit at Wills Eye Hospital and professor of ophthalmology at Jefferson.

On visits to the optometrist, the participants were prescribed low-vision devices such as handheld magnifiers. After those initial visits, the participants were randomly split into two groups. One group received behavior activation from a trained occupational therapist, who guided the participants on how to use the low-vision device and make changes at home like use brighter lights and high-contrast tape. They were also given positive reinforcement through increased social activities and help in setting and managing personal goals. 

"Blending the behavior activation with low-vision rehabilitation was straightforward and natural," said Dr. Mark Hegel, also a co-author. "Occupational therapy helps people regain valued activities in their daily lives, and behavior activation capitalizes on this through formal goal setting and reinforcement of progress." 

The second group was a control group, and though they got time with a therapist, they did not receive behavior 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 percent did so. All participants also received their meds as prescribed by their primary eye care providers. 

By four months, 12 participants in the control group and seven participants in the behavior activation group had withdrawn from the trial or passed away. Of the remaining 169 participants, 18 in the control group and 11 in the behaviour activation group developed clinical depression, based on retesting with the PHQ-9. 

Behavior activation had the most benefit for participants with the worst vision (less than 20/100), reducing the risk of depression by about 60 percent compared to controls. When the data were adjusted for vision status, physical health, and baseline PHQ-9 score, behavior activation reduced the risk of depression by 50 percent compared to the control treatment. 

"AMD is typically diagnosed and treated in primary eye care settings, where there is no defined standard of care for depression. This study was a unique and compelling effort to address that issue by strengthening teamwork between eye care professionals and mental health professionals," said Dr. Eleanor Schron, group leader for clinical applications at NEI. 

Dr. Rovner feels that since depression in AMD is rarely detected, as a public health initiative, more research needs to be carried out in this area. Behavior activation can be covered under Medicare when approved by a physician, he says. 

A strong collaboration between vision and mental health workers is needed to make this treatment widely accessible to AMD patients. The study will continue to track the patients to see if the approach retains its benefits up to a year. 

Source: Rovner B, Casten R, Hegel M, et al. Low Vision Depression Prevention Trial in Age-Related Macular Degeneration, Ophthalmology. July 2014.