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Behavior therapy may help prevent depression over vision loss

By Kathryn Doyle

NEW YORK (Reuters Health) - Combining occupational therapy to help older people adapt to central vision loss with behavior therapy to keep them from becoming too isolated may prevent depression, according to a new study.

Age-related macular degeneration (AMD) causes vision loss in the center of the retina, eventually leaving only peripheral vision and making activities like reading and driving difficult or impossible.

Most people do not regain their lost vision, and up to 30 percent of patients develop clinical depression, the study authors write in the journal Ophthalmology.

“Vision is the primary way that people engage their world, when you compromise that with AMD it disengages people from the world,” said lead author Dr. Barry W. Rovner. “It’s not surprising that people get depressed.”

According to his team’s results, even for people over 80, offering low vision rehabilitation and behavioral therapy can help alleviate that depression problem, Rovner told Reuters Health.

Rovner worked on the study at the Jefferson Hospital for Neuroscience in Philadelphia. To begin, 188 patients with AMD and some symptoms of depressed mood but no depressive disorder yet, visited an optometrist twice for vision assessments and got prescriptions for visual aid devices, like magnifiers.

The patients, whose average age was 84, were then divided into two groups. One group was visited by a social worker in the home six times over an eight-week period. The so-called social therapy sessions provided an opportunity to talk about living with reduced vision and therapists offered emotional support.

The other group had a similar series of in-home visits, but from an occupational therapist, who suggested ways to make seeing easier in the home, like new or better lighting or using reflective tape.

As part of “behavior activation” therapy, the occupational therapist also helped patients set goals for activities they would like to resume and for making more social connections, as well as offering practical advice, such as breaking down larger tasks into smaller, manageable ones.

“A lot of participants in this study had stopped going out of the house due to fear of falling or getting lost and became more socially isolated,” Rovner said. “The occupational therapist helped them devise strategies to reengage in the world again.”

For example, he said, for a patient who may have enjoyed going for walks but had stopped due to vision loss, the therapist would help her pick a friend to go with her, set a time and date, and suggest using a pedometer.

Four months after the study began, 18 patients in the social therapy group had developed a depressive disorder, compared to 11 in the behavioral activation group.

Neither group scored higher on general quality of life assessments after the therapies, but that doesn’t mean this wasn’t an effective strategy, said Dr. Joseph Eichenbaum, an ophthalmologist specializing in geriatric vision loss at The Mount Sinai Hospital in New York.

“There’s nothing new or novel here but it shows you can get somewhere, you could get nice results from behavioral therapy and low vision assistance,” said Eichenbaum, who was not involved in the study.

It likely takes more than four months to change someone’s quality of life, he told Reuters Health. The depression caused by profound vision loss, similar to that caused by the loss of a dear friend or spouse, isn’t going to respond well to antidepressants or drugs.

Physically adapting to the change, and modifying your behavior, is the best bet, Eichenbaum said, although some people have trouble doing that.

Some people are embarrassed to admit they have vision loss, or to use magnifiers, but those kinds of tools can help regain some function, he said.

Since both types of therapy involved home visits, the reduced depression rate in the behavioral activation group had to be due to more than just the increased attention, which is important to note, Rovner said.

“Medicare does pay for occupational therapists to come to your home to do these things if there’s a recommendation from an ophthalmologist, but reimbursement is so low that there are not a lot of therapists doing this,” he said.

“There is a model for treatment, but we have to change the incentives,” he said.

People struggling with vision loss should look not only for an eye doctor, but specifically for a low-vision optometrist, who should be able to help locate other community resources, he said.

SOURCE: http://bit.ly/1q9yq32 Ophthalmology, online July 9, 2014.

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