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Effect of Depression on Vision Function

in Age-Related Macular Degeneration


Barry W. Rovner, MD; Robin J. Casten, PhD; William S. Tasman, MD
Objectives: To report the prevalence rate of depres-
sion in older patients with recent vision loss due to age-
related macular degeneration (AMD) and to describe the
effect of depression on self-reported vision function dur-
ing 6 months.
Methods: Prospective cohort study of 51 older pa-
tients withrecent-onset bilateral AMDattending the Retina
Clinic of Wills Eye Hospital, Philadelphia, Pa. Main out-
come measures included the Center for Epidemiologi-
cal Studies Depression Scale, visual acuity, Functional Vi-
sionScreening Questionnaire, Chronic Disease Score, and
Community Disability Scale.
Results: Seventeen patients (33%) were depressed at
baseline and had worse visual acuity (P=.04) and greater
levels of vision-specific (P=.03) and general (P=.002)
physical disability than nondepressed patients. The cor-
relations of Center for Epidemiological Studies Depres-
sion Scale score with visual acuity and visual-specific dis-
ability, however, were not significant after controlling for
general physical disability. Anincrease indepressive symp-
toms over time predicted decline in self-reported vision
function independent of changes in visual acuity or medi-
cal status (P.05).
Conclusions: The prevalence and disabling effects of
depression in older patients with AMD are substantial.
Recognizing that depression is a treatable disorder that
exacerbates the effects of AMDwill lead to improved out-
comes. Innovative interventions to prevent or treat de-
pression in specialty eye clinics are possible.
Arch Ophthalmol. 2002;120:1041-1044
T
HEPREVALENCEanddisabling
effects of age-related macu-
lar degeneration(AMD) are
increasingas thepopulation
ages.
1
Williams,
2
Mangione,
3
and Scott
4
et al demonstrated that AMD
causes highlevels of emotional distress and
reducedqualityof life. However, whereasthe
first 2studiesnotedweak, nonsignificant re-
lationshipsbetweenvisual acuityandquality-
of-lifemeasures, thelatter foundthat worse
visual acuitywas associatedwithemotional
distress.
2-4
Brodyet al
5
foundhighratesof de-
pressionandsignificantcorrelationsbetween
depression and vision-specific and general
disabilitybutnotwithvisual acuity.
5
Wehave
previously found that the relationship be-
tweenvisual acuityanddepressionis medi-
ated by the loss of valued, discretionary ac-
tivities.
6
These studies showthat, although
AMDsubstantiallydisruptsthequalityof pa-
tients lives, its disabling effects and not its
severity per se predict depression.
The studies cited above have been
cross sectional, however, and are con-
foundedby the reciprocal relationships be-
tween depression and disability (ie, dis-
ability leads to depression, depression
exacerbates disability). There have been
no longitudinal studies investigating
changes invisual acuity, disability, and de-
pression to clarify these relationships, to
our knowledge. In this prospective study,
we report the prevalence rate of depres-
sion in older patients with recent-onset bi-
lateral AMD and describe the longitudi-
nal relationships betweenchanges invisual
acuity, vision function, and depression in
these patients.
RESULTS
Seventeen patients (33%; 95% confi-
dence interval [CI], 19.9-47.0) were de-
pressed (CES-Dscore 16) at baseline (ie,
6 weeks after visionloss inthe secondeye).
Table 1compares their demographic and
clinical characteristics with those of the 34
nondepressed patients. Depressed sub-
jects had worse visual acuity and greater
levels of both vision-specific and general
physical disability than nondepressed pa-
tients but were otherwise comparable in
severity of comorbidmedical disorders and
demographic characteristics.
Depression scores were signifi-
cantly correlated with vision-specific dis-
ability (r=0.31; 95% CI, 0.04-0.54), gen-
CLINICAL SCIENCES
From the Departments of
Psychiatry and Human
Behavior (Drs Rovner and
Casten) and Ophthalmology
(Dr Tasman), Jefferson Medical
College, Thomas Jefferson
University, and Wills Eye
Hospital (Dr Tasman),
Philadelphia, Pa.
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eral physical disability (r=0.57; 95%CI, 0.36-0.93), and
logMAR(r=0.34; 95%CI, 0.07-0.56) (all P.05) but not
with CDS (r=0.04). The LogMARwas significantly cor-
related with vision function (r =0.41; 95% CI, 0.15-
0.72; P.003) but not with general function (P=.9).
Table 2shows the results of a multiple regression analy-
sis with CES-D score as the dependent measure. Vision
function, general function, visual acuity, and CDS were
the independent measures andwere enteredonone block.
Only general function was significant (P.001), indi-
cating that vision-specific disability and acuity were not
uniquely related to depression after controlling for physi-
cal disability. We found identical results in models in-
cluding either vision-specific disability or visual acuity
but not both simultaneously.
There were complete 6-month follow-up data on 40
(78%) of the 51 subjects. We compared the 40 subjects
with complete data with the 11 without and found no
differences indemographic characteristics, function(both
vision-specific and general), or visual acuity. Those with-
out complete data, however, had higher mean CES-D
scores at baseline (mean, 17.3; SD, 8.8) than subjects with
complete data (mean, 10.5; SD, 7.7; P=.02). Other re-
search confirms that older subjects lost to follow-up in
longitudinal studies tend to be more depressed and less
physically healthy.
15
This suggests that our results might
be biased toward more functional patients with AMDand
underestimate the psychological needs of patients with
AMD. Of the 13 patients with depression at baseline on
whom follow-up data were available, 7 remained de-
pressed at 6 months. The 6 remitted patients contin-
ued to have depressive symptoms (mean CES-D score,
10.8; SD, 3.8), however, exceeding that reported in older
persons in the community (mean CES-Dscore, 8.06; SE,
0.19).
16
One depressed subject was treated for depres-
sion at baseline and 2 were treated at 6 months.
To examine change over time, we performed a se-
ries of paired t tests comparing baseline with 6-month
PATIENTS AND METHODS
We screened consecutive patients at the Wills Eye Hospi-
tal Retina Service, Philadelphia, Pa, to identify those with
preexisting AMD in one eye with visual acuity worse than
20/70, who had vision loss in the second eye due to exu-
dative AMD within the preceding 6 weeks resulting in vi-
sual acuity worse than 20/70. We chose these criteria to
identify subjects with sufficiently impaired vision to cause
functional limitations and recent onset of bilateral vision
loss. Additional inclusion criteria were age greater than 64
years and residence within 25 miles of Wills Eye Hospital.
We excluded cognitively impaired subjects (eg, 3 or more
errors onthe Kahn-Goldfarb Mental Status Questionnaire).
7
Potential subjects (N=109) were screened from Janu-
ary 1, 1998, to July 31, 1998, until the planned enrollment
of 51 subjects was completed. We based this sample size on
the previously reported strong correlation (r=0.44; confi-
dence interval, 0.19-0.64) of the Geriatric Depression Scale
with general function in visually impaired subjects.
8
With
the proposed sample of 51, the study has 92.9% power
(=.05, 2-tailed) to detect a moderate correlation between
depression and disability. Sixty-four subjects met the inclu-
sion criteria and 51 (79.7%) agreed to the in-home clinical
interview. There were no differences in demographic or
vision characteristics between those who refused and sub-
jects who were enrolled. We reinterviewed 46 subjects (90%
of those enrolled) 6 months later. The Thomas JeffersonUni-
versity institutional review board approved this investiga-
tion; all subjects provided informed signed consent. The
Batelle Center for Public Health Research and Evaluation,
Baltimore, Md, conducted the in-home interviews. Two
graduate-level professional surveyors assessed depressive
symptoms and visual and physical disability. Ophthalmo-
logic diagnoses and distance acuity were ascertained from
subjects Wills Eye Hospital records.
We evaluated depression by means of the Center for
Epidemiological StudiesDepression(CES-D) Scale.
9
This in-
strument contains 20 items that assess the severity and fre-
quency of depressive symptoms during the past week. The
CES-D scores range from 0 to 60; higher scores indicate
more severe depressive symptoms. A score of 16 or higher
has high sensitivity and specificity rates for identifying sub-
jects with depressive disorder.
10
Patients with CES-Dscores
greater than 16 were categorized as depressed in this study.
Baseline visual acuity (best-corrected distance visual
acuity in the better eye) was measured at Wills Eye Hos-
pital by means of the Snellen eye chart. Visual acuity at 6
months was obtained from Wills Eye Hospital and com-
munity ophthalmologists records. Distance acuity was trans-
formed into the logarithm of the minimum angle of reso-
lution(logMAR), whichconverts visual fractions to a metric
value more easily fitted to statistical analyses.
We used the Chronic Disease Score (CDS) to provide
an objective measure of medical morbidity derived from a
weighted sum of medications taken for chronic disease.
11
Clark et al
12
validated the CDS on more than 250000 man-
aged care enrollees and found that it predicts healthcare uti-
lization, costs, hospitalization, and mortality.
12
The CDS is
scored as projected yearly total health care costs in dollars.
We assessed vision-related disability by means of the
Functional Vision Screening Questionnaire, which con-
sists of 15 self-rated yes-no items that rate performance on
vision-related tasks (eg, watching television, reading news-
print, recognizing faces, driving). Scores range from 0 to
15, with higher scores indicating greater disability. Ascore
of 9 has sensitivity of 0.72 and specificity of 0.94 to detect
patients witha corrected distance acuity of 20/70 or worse.
13
The term vision function refers to self-rated Functional Vi-
sion Screening Questionnaire scores.
We used the Community Disability Scale to assess ac-
tivities of daily living, instrumental activities of daily liv-
ing, and mobility.
14
This 28-item instrument was used in
the East Baltimore Mental Health Epidemiologic Catch-
ment Survey on 175000 adults. Higher scores indicate
greater disability.
Initial analyses consisted of comparing subjects who
were and were not depressed at baseline by means of 1-way
analyses of variance and
2
for linear and categorical vari-
ables, respectively. Amultiple regression analysis was used
to delineate correlates of baseline CES-D score. Six-
month change in vision function was evaluated with a sepa-
rate multiple regression.
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data for visual acuity, CES-Dscore, vision function, gen-
eral function, and CDS. There were significant declines
in vision function (P=.005) and general function (P=.01)
but no significant changes invisual acuity (P=.24), CES-D
(P=.26), or CDS (P=.98). To assess change invisionfunc-
tion in relation to changes in CES-D and visual acuity,
we first examined the zero-order correlations between
the change scores. Change in vision function was sig-
nificantly correlated with change in CES-D (r=0.32;
P=.03) but not withchange inlogMAR(r=0.04; P=.83).
We then performed a hierarchical linear regression to de-
termine whether the significant correlation between
change in vision function and change in CES-Dwas sus-
tained when baseline CES-D score and change in visual
acuity were controlled. The dependent variable was change
in vision function, and both baseline visual acuity and
change in acuity were entered on the first step. Baseline
CES-D scores and change in CES-D were entered on the
second step. As indicated in Table 3, only change in
CES-D(worsening depression) was significantly related
to change (decline) in vision function. These data sug-
gest that the process of worsening depressive symp-
toms, rather thantheir absolute level at baseline or change
in acuity over 6 months, is related to vision function.
COMMENT
This investigation reports the prevalence and impact of
depression in this particular population of older per-
sons with bilateral AMD. Its strengths are its prospec-
tive designand systematic ascertainment, assessment, and
follow-up of subjects whose affective, medical, and func-
tional characteristics were carefully characterized by
means of reliable and valid instruments. The studys limi-
tations are its small size, limited generalizability given
the specific inclusion criteria and attrition (which may
underestimate the effects of depression), reliance on vi-
sual acuity as the sole measure of AMDseverity, and the
use of a self-reported vision function measure less well
validated than the National Eye Institute Visual Func-
tion Questionnaire or Activities of Daily Vision Scale.
17,18
In fact, our use of a self-report rather than a performance-
based measure of vision function cannot control for the
potentially confounding effect of depression on self-
ratings of function.
19
We found high rates of depression at 6 weeks after
vision loss in the second eye. The 33% rate exceeds the
16%rate reported in2 community populationstudies and
is comparable with the 35.2% rate reported in primary
care with the use of the same method to diagnose de-
pression.
10,19,20
It agrees with Brody and coworkers re-
port
5
of a 32.5% prevalence rate of depressive disorder
in patients with advanced AMD. Because only 1 subject
in this study was receiving treatment for depression at
baseline, we suspect that the rate of preexisting depres-
sion (before vision loss in the second eye) was ex-
tremely low.
Table 1. Comparison of 17 Depressed and 34 Nondepressed Subjects on Baseline Characteristics*
Depressed
(n = 17 [33%])
Nondepressed
(n = 34 [67%]) P Value
Total Sample
(N = 51)
Mean (SD)
Age, y 82.1 (6.4) 80.8 (6.4) .49 81.3 (6.4)
Education, y 11.0 (3.8) 10.9 (3.6) .96 11.0 (3.6)
Baseline CES-D 21.6 (4.8) 7.1 (4.8) .001 11.9 (8.4)
Baseline LogMAR 0.96 (0.43) 0.74 (0.29) .04 0.81 (0.35)
Baseline vision function 10.1 (3.6) 7.6 (3.8) .03 8.5 (3.9)
Baseline general function 16.8 (8.8) 8.7 (8.4) .002 11.4 (9.3)
Chronic Disease Score, $ 2353 (1011) 2672 (1143) .33 2566 (1102)
No. (%)
Female 14 (82) 23 (68) .27 37 (73)
Married 7 (41) 12 (35) .68 19 (37)
Widowed 9 (53) 18 (53) .99 27 (53)
Living alone 7 (41) 16 (47) .69 23 (45)
*Depressed subjects had a score of 16 or more on the Center for Epidemiological Studies Depression (CES-D) Scale.
Table 2. Multiple Linear Regression
Predicting CES-D (n = 50)*
Variable
Partial
Correlations
Visual acuity 0.16
Visual function 0.04
Total r = 0.604
General function 0.51
Chronic Disease Score 0.13
*CES-D indicates Center for Epidemiological Studies Depression Scale.
P.001.
Table 3. Multiple Regression
Predicting in Vision Function (n = 40)*
Variable
Partial
Correlations Total r
Step 1
Baseline acuity 0.04
0.05
Change in acuity 0.05
Step 2
Baseline acuity 0.01
Change in acuity 0.10
0.386
Baseline CES-D 0.18
Change in CES-D 0.37
*CES-D indicates Center for Epidemiological Studies Depression Scale.
P.05.
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Depressedpatientshadmoregeneral andvision-specific
disabilitythannondepressedpatients andslightlyworsevi-
sual acuity, althoughthecorrelations betweenCES-Dscore
andbothvision-specificdisabilityandvisual acuitywerenot
significant aftercontrollingforgeneral disability. Thesefind-
ings agree with those of others reporting weak or nonsig-
nificant relationshipsbetweenvisual acuityanddepression,
and others reporting reciprocal relationships between dis-
abilityanddepressioninolder patients withchronic medi-
cal diseases.
2-5,21,22
However, becausemanynonophthalmo-
logicdiseases (eg, cardiovascular diseaseandcancer) share
symptoms withdepression(eg, fatigue and anorexia), dis-
entangling their effect ondisability has beendifficult. Age-
relatedmaculardegenerationprovidesauniquediseasemodel
toexaminetheseinterrelationshipsbecauseitsharesnosymp-
toms withdepression. Our longitudinal datasuggest that as
depressive symptoms increase over time, there is a corre-
spondingdeclineinvisionfunctionoccurringindependently
of change in visual acuity. We found a similar effect when
depressionwas analyzedas thecategorical diagnosis of ma-
jor depression.
23
Thecurrent report extends that findingby
demonstratingthatvisionfunctiondeclinesinpatientswhose
depressionsymptoms increase, regardless of whether they
meet criteria for major depression. The psychological and
somatic symptoms of depression probably account for its
adverseeffect onvisionfunction. Discouragement andhelp-
lessnessdraininnerresolveandresiliency, andanergia, poor
appetite, and sleep impair effortful behaviors.
Ophthalmologists are well aware of the emotional con-
sequences of AMDand have been as frustrated in their ef-
forts to respond to depression as they are to restore vision.
Unfortunately, many obstacles prevent them from treat-
ing depression, such as resource and time constraints and
lack of familiarity with treatment indications and psycho-
tropic medications. As a result, depression remains an un-
treated source of excess disability in many patients. Our
findings attest to these disabling effects of depression but
also suggest that interventions may be helpful. Recogniz-
ing that depression is not simply an understandable con-
sequence of vision loss but rather a distinct, treatable dis-
order is a necessary first step. Second, ophthalmologists can
encourage patients and their families to seek psychiatric
care for demoralizationandhopelessness, especially if these
symptoms persist over time. Third, innovative interven-
tions to prevent or treat depression in specialty eye clinics
are possible. We are currently evaluating the efficacy of a
psychosocial intervention to prevent depression in older
persons withAMDina randomized, controlledclinical trial
funded by the National Institute of Mental Health. Brody
et al
24
already demonstrated the efficacy of a brief, behav-
ioral groupinterventiontoimprove mood, self-efficacy, and
use of visionaids ina similar population. Interventions such
as these, as well as others that includeeducationabout AMD,
increased access to community services, low-vision reha-
bilitation, support groups, home modifications, and treat-
ment of depression, may ultimately prevent depressionand
enhance functioning and quality of life. Until treatments
torestore visionare available, these approaches provide op-
timal care to patients with AMD.
Submitted for publication December 11, 2001; final revi-
sion received April 15, 2002; accepted April 24, 2002.
This study was supported by grant MH61331 fromthe
National Institute of Mental Health, Bethesda, Md, and a
charitable grant fromThe Ralston House, Philadelphia, Pa.
We thank Oneita M. Harmon for preparation of the
manuscript and Mitchell Feinman, MD, for ascertainment
of the sample.
Corresponding author and reprints: Barry W. Rovner,
MD, Geriatric Psychiatry, Wills Eye Hospital, 900 Walnut
St, Eighth Floor, Philadelphia, PA 19107 (e-mail:
Barry.Rovner@mail.tju.edu).
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