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Depression
And from these melancholy dispositions no man living is free .. none so wise, none so happy, none so patient, so generous, so godly, so divine, that can vindicate himself; so well-composed, but more or less, some time or other, he feels the smart of it.
What is depression? What causes it? How common is depression in visual impairment? Why is depression in people with visual impairment important? How should depression be treated? The promise of Problem-Solving Treatment (PST) DEPVIT: Depression in Visual Impairment Trial Take home messages
What is depression?
Depression is the 2nd leading cause of disability worldwide in people aged 15-44 Depression costs the UK economy 12 billion per year
Depression
Lifetime risk: 10-20%. Women: 2 times higher rate than men. Course of illness: Recovery is the rule. However, a relapsing course is common: 80% will have at least one more episode in their lifetime. The mean duration of an episode is 20 weeks. Suicide in 10% of patients who have ever been hospitalised for depression.
Causes of depression
Genetic predisposition (40% of risk) Early childhood adversity and stressful life events Physical illness Cognitive theories:
negative cognitive distortions depressogenic cognitive style
Biochemical abnormalities
Reduced serotonergic and noradrenergic neurotransmission
Endocrine abnormalities
Causes of depression
Genetic predisposition Early childhood adversity and stressful life events Physical illness, eg, visual impairment Cognitive theories:
negative cognitive distortions depressogenic cognitive style
Biochemical abnormalities
Reduced serotonergic and noradrenergic neurotransmission
Endocrine abnormalities
Spectrum conditions
Normal
Genetic predisposition
Depressed patients:
Have an increased risk of obesity and diabetes Are four times more likely than the general population to have a heart attack Are more susceptible to infections because of compromised immune systems
Depressed women have decreased bone mineral density and are at greater risk of hip fractures
Often have additional risk factors for ill-health, eg, they smoke more and use more alcohol
Depression, visual acuity, comorbidity and disability associated with age-related macular degeneration
Brody et al, 2001, Ophthalmology, 108:1893-1901.
Cross-sectional baseline data from a RCT 151 patients (mean age 80) with advanced MD
Formal diagnostic assessment 32.5% of participants had depressive disorder (twice the usual rate in the elderly) Depression strongly associated with both visionspecific and general disability scores
Follow-up study of 51 MD patients with recent loss of vision in second eye Assessed at baseline and 6 months later
At six months follow-up, those whose depression had worsened also had worsening visual and general functioning (independent of any change in visual acuity)
13.5% of visually impaired had a score of 6 or more on the Geriatric Depression Scale (compared to 4.6% with good vision) No association between visual impairment and anxiety
Controlling for problems with activities of daily living attenuated the association between visual impairment and depression
Bio-Psycho-Social approach:
Antidepressants
Problem-Solving Treatment
A psychotherapy that teaches problem-solving skills Tackles negative perceptions which interfere with an individuals ability to find practical solutions to problems Four key skills:
1. 2. 3. 4. Define the problem Set a realistic goal Generate, choose and implement a solution Evaluate the outcome
PST group also less likely to give up a valued activity (this mediated the effect of PST on depression)
By 6 months early benefits had diminished
DEPVIT - aims
1. How common are depressive symptoms in consecutive attendees of low vision services in Cardiff and London (N=1000)?
2. Does Problem-Solving Treatment help to reduce depression and improve functioning?
Randomised controlled trial (3 arms): Problem-solving treatment Letter to GP Waiting list control
Depression is treatable Problem-solving therapy is a promising new treatment The DEPVIT trial may lead to future changes in the assessment and care of people with visual impairment