Check Up: New treatment helps avert blindness-related depression

Jefferson's Barry Rovner said that most macular degeneration patients receive no mental health treatment.
Jefferson's Barry Rovner said that most macular degeneration patients receive no mental health treatment.
Posted: July 14, 2014

A type of therapy that combined training in emotional and physical coping skills helped patients who were facing blindness to avoid depression, a new study from Thomas Jefferson University has found.

Patients with age-related macular degeneration who got the experimental treatment at home were half as likely to become depressed as those who simply talked with a therapist about their illness and its consequences.

In the study, published last week in the journal Ophthalmology, 12.6 percent of patients who received a therapy called "behavior activation" became depressed, compared with 23.4 percent of the control group. All of the 188 patients in the study had mild depressive symptoms and were at risk for developing more serious depression. Their average age was 84.

The study involved researchers from Jefferson and Wills Eye Hospital (which serves as its ophthalmology department), Dartmouth Medical School, and Johns Hopkins University School of Medicine.

About two million Americans over the age of 50 have vision loss because of macular degeneration. It becomes more common with age, affecting 4 percent of people in their 80s and 12.5 percent of those above 90.

As it progresses, the disease causes a blurry spot near the center of vision that can make it hard to read, drive, watch television, or do anything else that requires clear eyesight. Research has found that people with macular degeneration may withdraw from activities they once enjoyed, putting them at higher risk for clinical depression.

Barry Rovner, a Jefferson geriatric psychiatrist who led the study, said that most macular degeneration patients receive no mental health treatment. He became interested in their problems because his office was located in Wills Eye Hospital and neighboring doctors began telling him about their patients' problems.

Allen Ho, a retina specialist at Wills, said it's easy enough to see why macular degeneration patients become depressed. "When you're a grandmother, what do you want to do?" he asked. "You want to read a book. You want to see your grandchild's face and you want to drive a car." Macular degeneration can make all of those things difficult.

Depressed patients are at higher risk for death, Rovner said, and require more costly care. Ho said they are also less likely to follow doctors' orders.

At first, Rovner said, he tried giving the eye patients antidepressants, but those didn't work. "The kind of depression people have when they lose their vision is not a kind of depression that pills make better," he said.

His elderly patients were discouraged and demoralized because of a new disability, not a problem with their brains.

He next tried "problem-solving therapy," an approach that urged patients to identify what's wrong and find a solution. It worked, but only a little.

For the study, Rovner developed a practical treatment that used a novel tactic: Occupational therapists, who usually focus on physical problems, were taught to help patients adjust both physically and emotionally.

The therapists, who visited patients at home six times over four months, helped patients brighten lights in their houses, use adaptive devices, or sit closer to the television. They also explained that the risk for depression grows when people stop doing what they enjoy.

If a patient liked to take walks, for example, but was afraid of falling, the therapist would develop a detailed plan for walking, including which friend to call and when to go. Patients were asked to write down how they felt when they did something that was likely to boost morale.

The idea, Rovner said, was to counteract the fears that were preventing patients from doing things they enjoyed.

To make sure that simply getting attention wasn't the key ingredient, the control group talked about their problems with a masters-level therapist. Rovner considered that a placebo.

Medicare will pay for occupational therapy when ordered by a physician, although Rovner said reimbursement is too low to support widespread use.

The approach, though, could potentially help any patient whose life was changed suddenly by a health problem such as a heart attack or stroke. "This kind of therapy is broadly applicable," Rovner said.

Ho said the study has inspired Wills Eye to give the mental health problems of its patients more attention. "We want to develop programs that address the whole patient," he said.

215-854-4944 @StaceyABurling

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