New Research: Stepped Care for Coping with Age-Related Vision Loss, Depression, and Anxiety

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New research from Europe indicates that stepped care – a type of treatment that can offer self-help and “as needed” options for coping with age-related vision loss and depression – can offer promise in dealing with depression and anxiety in visually impaired older adults.

Further, this stepped care approach (detailed below) could lead to standardized strategies for the screening, monitoring, treatment, and referral of visually impaired older adults with vision-related depression and anxiety.

From the British Medical Journal (BMJ)

The research, entitled Stepped care for depression and anxiety in visually impaired older adults: a multicenter randomised controlled trial, has been published in the November 23, 2015 edition of the British Medical Journal (BMJ), an online, open-access, peer-reviewed journal published by the British Medical Journal Group.

The authors are Hilde van der Aa; Ger van Rens; Hannie Comijs; Tom Margrain; Francisca Gallindo-Garre; Jos Twisk; and Ruth van Nispen, who represent the following institutions: VU University Medical Center, Amsterdam, Netherlands and the School of Optometry and Vision Sciences, Cardiff University, Cardiff, United Kingdom.

More about the Study

Excerpted from Stepped care may ward off depression in sight-impaired elderly, via Reuters Health:

For older people with age-related vision loss and at risk of developing depression, a type of treatment in which tailored options are only offered when necessary may help stave off both depression and anxiety, according to a recent European study.

Stepped-care delivery is aimed at long-term disease management that maximizes the effectiveness and efficiency of resources, the authors write in the BMJ. Patients start with lower intensity treatments and only progress to higher intensity interventions if they don’t respond to the first efforts.

Fifteen percent of visually intact older adults have symptoms of depression and around two percent have major depressive disorder, said Dr. Robin Casten of Thomas Jefferson University and the Jefferson Hospital for Neuroscience in Philadelphia, who was not part of the new study.

The researchers studied 265 people age 50 or older in Belgium or the Netherlands who had impaired vision and also some level of depression or anxiety, but less than required for a clinical diagnosis.

Half of the group received usual care while the other half was also enrolled in a stepped-care program involving occupational therapists, social workers and psychologists from low-vision rehabilitation organizations.

The providers began by monitoring patient progress with (a) “watchful waiting” for three months, then delivering (b) guided self-help programs based on cognitive behavioral therapy for three months, (c) problem-solving treatment for the next three months, and (d) referral to a general practitioner if necessary at the end of the program. Patients only moved from one type of treatment to another if they still had elevated symptoms of depression or anxiety.

The guided self-help program involved face-to-face meetings and telephone calls designed to promote awareness of depression and anxiety, negative thought patterns, and self-defeating thoughts, as well as pleasurable activities that can still be carried out with visual impairment. Problem-solving treatment involved seven one-hour face-to-face meetings with social workers who helped patients establish realistic goals, generate alternative solutions, and select the best solution.

Two years after the study began, and one year after all four consecutive treatments would have been completed, 62 people in the comparison group, or 46 percent, developed a depressive or anxiety disorder, compared to 38 people, or 29 percent, in the stepped-care group. About a third of people dropped out of the program before the two years were up.

More about the Stepped-Care Model and Protocols for Depression

From Stepped care for depression and anxiety in visually impaired older adults: a multicenter randomised controlled trial, with the full open-source article available online:

Step 1: Watchful waiting (three months)

  • The first step was a period of watchful waiting, involving an active decision not to treat the condition but, instead, to intermittently reassess its status.
  • The executive researcher contacted the patient by telephone at baseline (for about 15 minutes) and after three months of watchful waiting. (for about 15 minutes)
  • Patients could contact the executive researcher by telephone during this period if necessary.

Step 2: Guided self-help (three months)

In the second step, guided self-help, based on a written, digital, audio, and braille version of a self-help course based on cognitive behavioural therapy (with specific vision-related examples and exercises), was offered. The course was divided into seven chapters, aimed at:

  • Increasing awareness of depression and anxiety in relation to having a chronic visual impairment, and setting a personal goal.
  • Increasing awareness of fatigue and stress in relation to depression and anxiety in people with a visual impairment, and offering relaxation exercises.
  • Increasing awareness of pleasurable activities that can still be carried out despite the visual impairment, and encouragement to take action.
  • Identifying and replacing self-defeating thoughts with healthier thoughts by means of exercises based on rational emotive behaviour therapy.
  • Identifying negative thought patterns (for example, black and white thinking, catastrophic thinking) and replace unhelpful thoughts with helpful thoughts.
  • Identifying personal communication styles (passive, assertive, or aggressive), and learning to use an assertive communication style
  • Continuing to use learned skills by reflecting on everything that has been learnt and setting goals for the future.

Guidance was provided by trained and supervised occupational therapists (n=17) from the outpatient low vision rehabilitation organisations. Two face-to-face contacts took place at the beginning of the intervention (about 60 minutes each contact) and one to three telephone calls (for about 15 minutes each). In the meantime, patients followed the intervention at home.

Step 3: Problem solving treatment (three months)

  • In the third step, trained and supervised social workers (n=7) and psychologists (n=5) from the low vision rehabilitation centres offered problem-solving treatment.
  • A maximum of seven face-to-face contacts (about 60 minutes each) took place.

During each of these contacts, the seven steps of problem-solving treatment were completed:

  • Clarify the problem.
  • Establish realistic goals.
  • Generate multiple alternative solutions by brainstorming.
  • Explore pros and cons of the alternative solutions.
  • Select the best solution.
  • Conduct a plan to carry out the best solution.
  • Evaluate the process.

Step 4: Referral to a General Practitioner (GP)

  • When increased symptoms of depression and anxiety still persisted after problem-solving treatment, the executive researcher contacted the patient by telephone to refer him or her to their GP (about 15 minutes).
  • The executive researcher called the GP, who made an appointment with the patient to discuss further treatment and the use of drug treatment (about 15 minutes).

About the Study

From the article abstract:

Study question: Is stepped care compared with usual care effective in preventing the onset of major depressive, dysthymic, and anxiety disorders in older people with visual impairment (caused mainly by age related eye disease) and subthreshold depression and/or anxiety?

Methods: 265 people aged more than or equal to 50 were randomly assigned to a stepped care programme plus usual care (n=131) or usual care only (n=134). Supervised occupational therapists, social workers, and psychologists from low vision rehabilitation organisations delivered the stepped care programme, which comprised watchful waiting, guided self-help based on cognitive behavioural therapy, problem solving treatment, and referral to a general practitioner.

The primary outcome was the 24-month cumulative incidence (seven measurements) of major depressive dysthymic and/or anxiety disorders (panic disorder, agoraphobia, social phobia, and generalised anxiety disorder). Secondary outcomes were change in symptoms of depression and anxiety, vision related quality of life, health-related quality of life, and adaptation to vision loss over time up to 24 months’ follow-up.

Study answer and limitations: 62 participants (46%) in the usual care group and 38 participants (29%) from the stepped care group developed a disorder. The intervention was associated with a significantly reduced incidence, even if time to the event was taken into account. The dropout rate was fairly high (34.3%), but rates were not significantly different for the two groups, indicating that the intervention was as acceptable as usual care.

Participants who volunteered and were selected for this study might not be representative of visually impaired older adults in general (responders were significantly younger than non-responders), thereby reducing the generalisability of the outcomes.

What this study adds: Stepped care seems to be a promising way to deal with depression and anxiety in visually impaired older adults. This approach could lead to standardised strategies for the screening, monitoring, treatment, and referral of visually impaired older adults with depression and anxiety.

A Very Personal Reflection on Vision Loss, Depression, Personal Growth, and Independence

Audrey Demmitt, RN, BSN, is a nurse diabetic educator, VisionAware Peer Advisor, Support Group Advisor, and AFB Career Connect mentor. These are her reflections on grappling with – and ultimately overcoming – her vision loss-related depression:

Audrey Demmitt and her dog guide

Blindness is a thief of much more than just vision. It robs you of many things and the impact is life-changing. In the early stages of adjustment, loss is its anthem and grief is its mantle. Often, depression is a close companion of vision loss because the losses pile up and overwhelm one’s ability and internal resources to handle them. This was my experience.

In the beginning, I was not even aware of all the losses that would come as a result of my vision loss, which served to protect me. There are many kinds of losses to catalog. There is the actual sensory loss of vision: losing touch with the physical world and missing out on information, colors, and beauty.

Shattered dreams are another significant loss. There are material losses caused by blindness, like the loss of a job, car, home, or relationship. And there are internal, personal losses, such as self-esteem, confidence, social standing, identity, security, and purpose in life. Indeed, blindness is a greedy thief that seeks to destroy – if you let it.

Accept, Adjust, Cope, Reaffirm

The task is to learn to accept, adjust, cope, and reaffirm life as a person who is visually impaired. The process is a long farewell to who you once were and how you used to do things. It involves re-imagining life as a visually impaired person and reinventing yourself. It is a tall order, but the point is that you can learn to adjust, limit your losses, and reclaim your life.

You never quite finish adjusting. This is also true of personal growth. We are always growing as a result of our experiences. We are always adjusting to what life brings us: new stages, crisis, joys, challenges, set-backs and losses.

Learning that Emotions Come from What We are Thinking

There was a time when I was not “adjusting” very well to my vision loss. I was angry and felt life was unfair. I was afraid of the future. And I was depressed. In short, I was “stuck” and it affected every aspect of my life. Eventually, I sought counseling and began to understand the impact and implications of my vision loss.

I learned about depression; that there was no shame in it, which freed me to address it. Through cognitive therapy, I learned that our emotions come from what we are thinking; negative thinking results in negative feelings. This seemingly simple concept was a key to turning my depression around.

You can read more about Audrey’s emotional journey at From Personal Loss to Personal Growth and the Road to Independence on the VisionAware website.

Additional Information

Make a positive choice to reach out for support and services to enhance your independence and quality of life. VisionAware can help you find resources and connect to services. Consult the Directory of Services for your state. And learn about what others are doing through our blog series on the theme of personal independence.