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. (REPRINTED) ARCH OPHTHALMOL/ VOL 120, AUG 2002 WWW.ARCHOPHTHALMOL.COM 1041 2002 American Medical Association. All rights reserved. Downloaded From: http://www.jamapeds.com/ on 11/27/2013 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. (REPRINTED) ARCH OPHTHALMOL/ VOL 120, AUG 2002 WWW.ARCHOPHTHALMOL.COM 1042 2002 American Medical Association. All rights reserved. Downloaded From: http://www.jamapeds.com/ on 11/27/2013 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. (REPRINTED) ARCH OPHTHALMOL/ VOL 120, AUG 2002 WWW.ARCHOPHTHALMOL.COM 1043 2002 American Medical Association. All rights reserved. Downloaded From: http://www.jamapeds.com/ on 11/27/2013 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). REFERENCES 1. Fine SL, Berger JW, Maguire MG, Ho AC. Age-related macular degeneration. N Engl J Med. 2000;342:483-492. 2. Williams RA, Brody BL, Thomas RG, Kaplan RM, Brown SI. The psychosocial impact of macular degeneration. Arch Ophthalmol. 1998;116:514-520. 3. Mangione CM, Gutierrez PR, Lowe G, Orav EJ, Seddon JM. Influence of age- related maculopathy on visual functioning and health-related quality of life. Am J Ophthalmol. 1999;128:45-53. 4. Scott IU, Schein OD, Feuer WJ, Folstein MF, Bandeen-Roche K. 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