Stepped care may ward off depression in sight-impaired elderly

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.

"This way long-term disease management needs can be met - which is attractive for visually impaired older people who are likely to face further physical decline over time (eye diseases are often degenerative) that can lead to an increased risk of depression and anxiety - and the effectiveness and efficiency of resource allocation can be maximized," said lead author Hilde van der Aa of VU University Medical Center in Amsterdam, The Netherlands.

Visual impairment is associated with physical dysfunction, decreased mobility, limitations in daily life activities and increased dependency on others, van der Aa told Reuters Health by email.

"About one in three visually impaired older adults experience subclinical symptoms of depression and anxiety, which is about twice as high as the prevalence in normally sighted peers," she said.

Fifteen percent of visually intact older adults have symptoms of depression and around 2 percent have major depressive disorder, said 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 "watchful waiting" for three months, then delivering guided self-help programs based on cognitive behavioral therapy for three months, problem solving treatment for the next three months, and 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 have 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, 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.

After guided self-help, many patients were free of clinically significant symptoms. Only one in five moved to problem solving therapy and only one in 20 were referred to the general practitioner, van der Aa said.

"The first step is to screen for depression as it is notoriously under-detected and under-treated in this population," Casten said. "For the most part, older adults with impaired vision become depressed because of vision-related disability and disengagement in enjoyable and meaningful activities."

The stepped-care program allows for standard choices of screening, monitoring, treating and referring visually impaired older adults with depression and anxiety in order to prevent them from developing major disorders, van der Aa said.

Stepped-care has been recommended by the U.K. National Institute for Health and Care Excellence (NICE) guidelines as the preferred model to deal with depression and increase efficiency of resource allocation, she said.