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On World Health Day, Edith Holloway, Research Fellow, Centre for Eye Research Australia , writes about how few people with vision loss receive psychological intervention for depression, and what needs to be done to change that.
Depression is a leading cause of ill health and disability worldwide and according to the latest estimates from the World Health Organisation (WHO) more than 300 million people are now living with depression. People with vision loss are particularly vulnerable to experiencing depression, affecting around 1 in 3 adults with vision loss. Each ocular condition presents unique challenges for the individual and may contribute to feelings of hopelessness, despair and isolation. Refractive error, the leading cause of vision impairment globally,1 may have extensive social and economic impact, limiting educational and employment opportunities of otherwise healthy individuals. For age-related macular degeneration (AMD), effective treatment options are available to prevent blindness. However, these treatments are expensive and not available to all patients in many countries,2 thus, often older adults who are faced with AMD must adapt to ongoing and progressive visual loss which requires significant personal resources. Similarly, glaucoma often results in extensive and irreversible visual field loss or blindness due to the asymptomatic nature of the disease in the early stages. Because of its chronic nature, its potential for causing irreversible vision impairment or blindness, and the inherent side effects of the treatment, glaucoma often can impose a significant psychological burden to patients3. Diabetic retinopathy (DR) is one of the most common causes of vision impairment in the working-age population in many countries and consequently, is associated with a significant socioeconomic burden, decline in quality of life and an increased risk of diabetes distress and depression.
Physical and mental health are disconnected
Globally, physical and mental health are addressed in a disconnected way and there is substantial evidence that health care services are not organised in a way which supports an integrated response to the dual physical and mental needs of patients. We know from previous work conducted by our group in Australia (Centre for Eye Research Australia) and also our colleagues in the UK4 and The Netherlands,5 few people with vision loss receive psychological intervention for depression. Barriers such as stigma, health-care costs and practical barriers (e.g. poor mobility and health, lack of available transport) all contribute to this disparity.
To overcome this issue, it has been proposed that models of ‘integrated care’ be implemented within chronic disease management frameworks or rehabilitation programmes designed to support people in managing their condition. For example, the National Institute of Clinical Excellence (NICE) updated its depression treatment guidelines in 2009 (reviewed 2015) by including an emphasis on understanding and treating the vulnerability to depression of people with functional impairment resulting from chronic physical problems. The guidelines recommend that these services be ‘co-ordinated or integrated within the current rehabilitation program’ for the specific physical health problem being treated.
“Integrated people-centred health services means putting the comprehensive needs of people and communities, not only diseases, at the centre of health systems, and empowering people to have a more active role in their own health (WHO)”
In 2012, the Centre for Eye Research Australia partnered Australia’s leading provider of blindness and low vision rehabilitation services, Vision Australia, to commence a world first trial which seeks to provide an integrated, early intervention to manage depressive symptoms in adults attending low vision rehabilitation services. Vision Australia staff were trained to deliver a low-intensity, evidence-based psychological therapy (Problem Solving Treatment) to adults who screened positive for depressive symptoms. Preliminary findings show promise for both the effectiveness and cost-effectiveness of this integrated, staff-delivered model.
Hope for the future
Collaborative care, an evidence-based approach for supporting people with co-morbid physical and mental health problems using a multidisciplinary team, could also provide a framework to delivering more person-centred eye health services. Ophthalmologists, primary care providers and allied health professionals can all play a key role in supporting their patients with depression. Specifically for adults with vision impairment, collaborative care models could include the provision of tailored and co-ordinated services provided by ophthalmologists, optometrists, low vision rehabilitation staff, psychologists, social workers, and general practitioners across a range of services (e.g. outpatient hospital and community-based eye health services).
A final consideration is that the provision of integrated and collaborative models should not be limited to those people meeting formal diagnostic criteria for depression. As we know from previous studies conducted with patients who have AMD,6 physical health problems often involve learning to live with a long-term condition, which may require a process of internal adaptation and can be accompanied by significant functional impairment and social isolation. From a person-centred approach, the provision of integrated and collaborative psychological support may help people adapt and manage their health more effectively. Failure to do so can result in poorer outcomes and faster disease progression. The case for addressing the mental health needs of people with vision loss in a more integrated and collaborative way is indeed promising.
#LetsTalk #depression #mentalhealth
1. Naidoo et al. Optom Vis Sci 2016; 93:227-34.
2. Wong et al. The Lancet Global Health 2014; 2:e06-e116.
3. Diniz-Filho et al. Ophthalmology 2016; 123:754-9.
4. Nollett et al. Ophthalmology 2016; 123:440-1.
5. van der Aa et al. Qual Life Res 2014; 24:1-10.
6. Wahl et al. J Ophthalmol 2013; 2013:11.
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