Visual Impairment and Mental Health: Unmet Needs and Treatment Options

Figures & data

Figure 1 Bidirectional interaction between visual impairment and mental health problems.

Table 1 Self-Management (SM) Interventions

Study	Sample	Intervention	Control	Outcomes Assessed	Main Findings
Brody et al^Citation137 RCT	92 adults aged 60+ with AMD, legally blind in at least one eye	N=44: Six weekly, 2-hour group sessions consisting of education about the disease, group discussion, and behavioral and cognitive skills training to address everyday challenges	N=48: Waitlist	Emotional distress (POMS) Self-efficacy (AMD-SEQ) Health-related quality-of-life (QWB) General health and participation in activities (Health and Impact Questionnaire) Use of vision aids Covariates: Pre-intervention scores	Participants in SM reported greater reductions in psychological distress (particularly in anxiety and depression) (effect size^a=0.53), improvements in self-efficacy (effect size^a=0.47), and increased use of visual aids in comparison to controls No change in health-related quality-of-life reported in the SM group
Brody^Citation138,Citation139 RCT	252 adults ages 60+ with AMD, visual acuity 20/60 or worse in the better eye and 20/100 or worse in the other eye (with correction)	N=92: Six weekly, 2-hour group sessions consisting of didactic presentations, group problem-solving with guided practice, and behavioral and cognitive skills training to address everyday challenges	N=79: Audio-recorded education program N=81: Waitlist	Emotional distress (POMS) Health-related quality-of-life in relation to vision (NEI-VFQ) Mediators: Social Support (DSSI-11); Optimistic vs pessimistic outlook (LOT-R); Self-Efficacy (AMD-SEQ) Covariates: Visual acuity	Participants in the SM group who met diagnostic criteria for a depressive disorder reported a greater reduction in distress (P=0.001) and improvements in functioning (P=0.02) than did depressed and non-depressed participants in the control conditions In the whole sample decreased emotional distress was associated with increased self-efficacy (r=−0.50) In the SM group, change in self-efficacy was a significant mediator of reduction in distress (P=0.03); change in self-efficacy (P=0.02) and perceived social support (P=0.03) were significant mediators of improvement in functioning After 6 months, SM participants with depression reported significantly lower levels of psychological distress (P<0.001) and higher levels of functioning (P=0.01) in comparison to depressed and non-depressed controls Compared to controls, SM participants were less likely to develop a depressive disorder over the follow-up period (P=0.05) In the SM group, change in self-efficacy was a significant mediator of reduction in distress (P=0.002) and improvement in functioning (P=0.02) after 6 months
Brody et al^Citation140 RCT	32 adults aged 60+ with AMD, visual acuity 20/60 or worse in the better eye and 20/100 or worse in the other eye (with correction), met clinical criteria for a depressive disorder	N=12: Six weekly, 2-hour group sessions consisting of didactic presentations, group problem-solving with guided practice, and behavioral and cognitive skills training to address everyday challenges	N=20: Audio-recorded education program or Waitlist	Depressive symptoms (GDS-15) Health-related quality-of-life in relation to vision (NEI-VFQ) Mediators: Social Support (DSSI-11); Optimistic vs pessimistic outlook (LOT-R); Self-Efficacy (AMD-SEQ)	Participants with a depressive disorder diagnosis and high levels of depressive symptoms at baseline reported significantly fewer depressive symptoms 6 months after receiving SM than did controls with concurrent depression and comparable baseline depression scores (P=0.03) The mean score change from baseline to 6 months post-intervention was clinically meaningful (2 point reduction) in the SM group In the SM group, increase in self-efficacy was associated with reduction in depressive scores (P<0.05) Six months post-intervention SM and control participants did not differ in terms of functioning
Girdler et al^Citation141 RCT	77 adults aged 65+ with age-related vision loss, visual acuity 6/12 or less in both eyes	N=36: Usual care + SM (Six weekly, 2-hour group sessions consisting of didactic presentations, group problem-solving with guided practice, and behavioral and cognitive skills training to address everyday challenges)	N=41: Usual care	Participation level (ACS) Depressive symptoms (GDS‐15) Quality-of-life (SF-36) Self-efficacy (GSES) Adaptation (AVLS) Vision specific self-efficacy (AMD-SEQ) Covariates: Pre-intervention scores	Following the combined treatment (SM+usual care), participants reported greater participation in life situations (effect size^b=0.20) and adaptation to vision loss (effect size^b=0.27), fewer depressive symptoms (effect size^b=0.20), better physical and mental quality-of-life (effect size^b=0.07-0.10), and increased self-efficacy (effect size^b=0.20-0.30) compared to participants receiving usual care alone, and nearly all of these effects were maintained up to 12-weeks post-treatment
Rees et al^Citation142 RCT	153 adults aged 55+ with age-related vision loss, visual acuity <6/12 and >6/480 in the better eye (with correction)	N=93: Low vision SM program (Eight weekly, 3-hour group sessions consisting of education about the disease, group discussion, problem-solving skills training, and goal planning)	N=60: Usual care (low vision rehabilitation service)	Vision specific quality of life (IVI) Distress (DASS) Self-efficacy (GSES) Adaptation (AVL12)	No significant differences between participants receiving SM in addition to usual care and those receiving usual care only, in regards to vision-related quality-of-life, emotional distress (ie, depression, anxiety, and stress), adaptation to vision loss, and self-efficacy at 1 and 6-months post-treatment A lack of between-group differences may be because sample included individuals with a wide range of eye conditions (not just AMD), therefore program could not address disease-specific issues

Notes: ^aEffect size is calculated as ([intervention group mean change] – [control group mean change])/(preintervention SD); ^bPartial eta squared where small=0.10, medium=0.30 and large=0.50.

Abbreviations: ACS, Activity Card Sort; AMD, age-related macular degeneration; AMD-SEQ, Macular Degeneration Self-Efficacy Scale; AVLS, Adaptation to Vision Loss Scale, Adaptation to Vision Loss Scale – 12 item; DASS, Depression, Anxiety, Stress Scale; DSSI-11, Duke Social Support Index 11 item; GDS-125, Geriatric Depression Scale; GSES, Generalized Self-Efficacy Scale; IVI, Impact of Vision Impairment Questionnaire, LOT-R, Life Orientation Test–Revised; NEI-VFQ, National Eye Institute Visual Function Questionnaire; POMS, Profile of Mood States; QWB, Quality of Well-Being Scale; SF-35, Short Form-36 Health Survey; SM, self-management.

Table 2 Problem-Solving Treatment (PST)

Study	Sample	Intervention	Control	Outcomes Assessed	Main Findings
Rovner et al^Citation144,Citation147 RCT	206 adults ages 64+ with AMD, neovascular AMD in one eye diagnosed within the past 6 months and pre-existing AMD in the other eye	N=105: Six 45–60 minute in-home sessions over 8 weeks, consisting of problem-solving skills (ie, how to define problems, establish realistic goals, generate, choose, and implement solutions, and evaluate outcomes); treatment is delivered by trained therapists and nurses	N=101: Usual care	Depressive disorder diagnosis Depressive symptoms (HDRS) Self-rated vision disability (NEI-VFQ) Mediators: Loss of values activities Covariates: Pre-intervention scores	Two months after intervention end, 23.2% of the usual care group met criteria for a depressive disorder, while only 11.6% of patients in the PST group met criteria; participants who received PST were less than half as likely to develop a depressive disorder (P=0.03) Six months after intervention end there was no significant difference between groups in depressive disorder prevalence In the PST group, only 36.4% of patients who met criteria for depression at treatment end were depressed at 6 months, whereas 72.2% of controls remained depressed throughout the follow-up period, suggesting PST may have delayed the onset of depression, but additional sessions may have been needed in order to prevent the emergence of depression altogether Participants receiving PST were less likely to relinquish a valued activity, which was identified as a mediator in the relationship between PST and reduced depression at 2 months (P=0.02) PST participants reported improved subjective vision function at 2 months, despite no change in objective acuity (P=0.04) 34 of 49 subjects reporting minimal depressive symptoms developed a depressive disorder within 6 months 75.6% of those reporting minimal depression at baseline developed a depressive disorder at 2 or 6 months, compared to 17.8% of those reporting even fewer depressive symptoms
Rovner et al^Citation149 RCT	241 adults ages 65+ with bilateral AMD (neovascular and/or geographic atrophy), visual acuity between 20/70 and 20/400 in the better-seeing eye, and moderate difficulty in a valued vision-function goal (eg, reading mail, attending social activities)	N=121: Sessions consisting of problem-solving skills (ie, how to define problems, establish realistic goals, generate, choose, and implement solutions, and evaluate outcomes); treatment is delivered by trained BA and MA level therapists	N=120: Supportive therapy (similar to PST, but no problem-solving skills training)	Targeted vision function (Activities Inventory) Vision function and quality-of-life in relation to vision (NEI-VFQ) Vision status (visual acuity, contrast sensitivity, central scotomas) Physical health status (CDS) Depressive symptoms (PHQ-9) Coping strategies (OPS) Covariates: Pre-intervention scores and vision severity stratification	After 3 and 6 months, both groups had similar improvements in targeted vision function scores No between- or within-group changes in depressive symptoms, vision function, or use of low vision devices were observed at 3 or 6 months Participants receiving PST had greater improvements in vision-related quality-of-life (P=0.05; P=0.05) and increased use of adaptive coping strategies (P<0.0001; P=0.015) 3 and 6-months post-treatment compared to those receiving supportive therapy
Nollett et al^Citation120 RCT	85 adults ages 18+ (mean age range 67–72), attending a low-vision center, with significant depressive symptoms (GDS-15 ≥6)	N=24: PST (6–8 45–60 minutes in-home sessions, consisting of problem-solving skills such as how to define problems, establish realistic goals, generate, choose, and implement solutions, and finally, evaluate outcomes) N=31: Physician referral	N=20: Waitlist	Depressive symptoms (BDI-II; GDS‐15) Self-rated vision disability (NEI-VFQ) Near visual function (VFQ-48) Health-related quality-of-life (EQ-5D) Mediators: Social Support (DSSI-11); Optimistic vs pessimistic outlook (LOT-R); Self-Efficacy (AMD-SEQ)	A similar reduction in depressive symptom severity was observed across all groups 6 months after intervention end; participants with moderate-to-severe depressive symptoms at baseline demonstrated the greatest reduction Changes in depression scores in the intervention groups did not reach clinical significance
Holloway et al^Citation148	62 adults ages 18+ (mean age 62) with vision impairment, visual acuity <6/12 in the better-seeing eye (with correction), with at least mild depressive symptoms (PHQ-9 ≥5)	N=62: telephone-administered PST (6–8 45–60 minute telephone sessions, consisting of problem-solving skills such as how to define problems, establish realistic goals, generate, choose, and implement solutions, and finally, evaluate outcomes)	None	Depressive symptoms (PHQ-9) Vision-related quality-of-life (AQoL-7D) Confidence in ability to use problem-focused coping (CSE)	37 participants withdrew from PST treatment over the course of the study, leaving only 25 completers (6–8 sessions) A 53% reduction in depressive symptom severity was observed at follow-up (P<0.001) In 67% of participants change in depressive symptom severity was clinically meaningful (PHQ-9 change ≥5 points) Clinically meaningful improvements in vision-related quality-of-ife (P<0.001), independent living (P=0.02), mental health (P=0.001), and coping (P=0.03) was observed following treatment Participants’ confidence in their ability to use problem-focused coping strategies improved by 18% (P=0.001) at treatment end

Abbreviations: AMD, age-related macular degeneration; AMD-SEQ, AMD Self-Efficacy Questionnaire; BDI-II, Beck Depression Inventory; CDS, Chronic Disease Score; CSE, Coping Self-Efficacy Scale; DSSI-11, Duke Social Support Index-11 item; EQ-5D, EuroQol Five Dimensions Questionnaire; GDS‐15, Geriatric Depression Scale; HDRS, Hamilton Depression Rating Scale; LOT-R, Life Orientation Test–Revised; NEI-VFQ, National Eye Institute Visual Function Questionnaire; OPS, Optimization in Primary and Secondary Control Scale; PHQ-9, Patient Heath Questionnaire; PST, problem-solving treatment; VFQ-48, Visual Function Questionnaire; AQoL-7D, Vision-Related Assessment of Quality-of-Life.

Table 3 Vision Rehabilitation Interventions

Study	Sample	Intervention	Control	Outcomes Assessed	Main Findings
Horowitz et al^Citation151	95 adults ages 65+ newly referred to a vision rehabilitation program	N=95: A combination of low vision clinical services (eg, prescription of adaptive devices and instruction on use), skills training (eg, skills of daily living, orientation and mobility training), and counseling depending on the needs and preferences of the individual	None	Vision rehabilitation service utilization (low vision clinical services, skills training, and counseling) Number of optical aids used (eg, magnifiers, special sunglasses) Number of adaptive aids used (eg, talking books, large print reading materials, large print telephone dial, special lighting) Depressive symptoms (CES-D) Covariates: Age; health status; vision status; functional disability; baseline depressive symptoms	Low vision clinical services was the most commonly used treatment component (received by 78% of sample) Approximately 21% of the study sample reporting baseline depression remained depressed at follow-up, while 13% experienced remission Greater use of low vision services (P<0.01), skills training (P<0.05), and optical (P<0.01) and adaptive (P<0.05) aids was associated with fewer depressive symptoms after 2 years Low vision clinical services significantly explained an additional 5% of the change in depressive symptom scores after 2 years (P<0.01), and counseling and use of optical devices each explained an additional 3% (Ps<0.05)
Horowitz et al^Citation152	584 adults aged 65+ newly referred to a vision rehabilitation program and with functional onset of the vision problem within the past 5 years	N=95: A combination of low vision clinical services (eg, prescription of adaptive devices and instruction on use), skills training (eg, skills of daily living, orientation and mobility training), and counseling depending on the needs and preferences of the individual	None	Functional disability (OMFAQ; IADL) Number of optical aids used (eg, magnifiers, special sunglasses) Number of adaptive aids used (eg, talking books, large print reading materials, large print telephone dial, special lighting) Depressive symptoms (CES-D) Covariates: Pre intervention scores; sociodemographic factors; rehabilitation service hours	Optical aids were used by 91% of the sample Greater use of optical aids after 6 months was associated with less functional disability (P<0.001) and fewer depressive symptoms (P<0.05) after 6 months Greater use of adaptive aids was associated with greater disability at after 6 months (P<0.001) The use of optical aids was associated with less functional disability (P<0.001) and fewer depressive symptoms (P<0.05) at 6 months Greater functional disability at baseline was a significant predictor of depressive symptom severity at 6 months (P<0.05)

Abbreviations: CES-D, Center for Epidemiological Studies Depression Scale; IADL, instrumental activities of daily living; OMFAQ, Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire.

Table 4 Cognitive Behavioral Therapy (CBT) Interventions

Study	Sample	Intervention	Control	Outcomes Assessed	Main Findings
Rovner et al^Citation153 RCT	188 adults aged 65+ with bilateral AMD (neovascular or geographic atrophy), visual acuity <20/70 in the better seeing eye with correction, moderate difficulty performing a valued vision-dependent activity, and subthreshold depressive symptom	N=96: BA+LVR consisting of six in-home 1-hour BA sessions over 8 weeks, focusing on promoting self-efficacy and social connection to improve mood and function, and action plans to accomplish personal and functional goals	N=92: ST+LVR consisting of six in-home 1-hour BA sessions over 8 weeks, focusing on personal expression about vision loss (ie, discussion of illness, disability, and vision loss)	Depressive disorder diagnosis (based on PHQ-9) Vision function and quality-of-life in relation to vision (NEI-VFQ; Activities Inventory) Vision status (visual acuity, contrast sensitivity, central scotomas) Physical health status (CDS; MOS-6) Personality (NEO-PI-R) Behavioral activation (BADS) Optical device use Mediators: Social impairment Covariates: Pre-intervention scores; visual acuity	At 4 months, the absolute risk reduction for the BA+LVR group was 11% and the number needed to treat to prevent one additional case of depression was nine Participants receiving BA+LVR were significantly less likely to develop a depressive disorder after 4 months compared to those receiving ST+LVR (P=0.04) Vision function improved in both groups, but the effect was larger in BA+LVR (effect size^a=0.72) group Social impairment was a partial mediator of the relationship between treatment group and depression-BA+LVR prevented depression to the extent that it increased social engagement
Kamga et al^Citation154 RCT	80 adults aged 50+ with late stage AMD or diabetic retinopathy, acuity in both eyes better than 20/200, and mild depressive symptoms	N=41: Self-guided CBT toolkit consisting of cognitive restructuring, problem-solving, and mood monitoring and telephone coaching with three 10-minute calls over 8 weeks	N= 39: Usual care	Depressive symptoms (PHQ-9) Anxiety symptoms (GAD-7) Life space (LSA) Self-efficacy (DMSES) Covariates: Visual acuity; psychiatric history (eg, antidepressant, psychotherapy use)	After 8 weeks, there was a significant reduction in depression scores in both groups, but depressive symptom scores in the CBT group were slightly lower (1.7 points) than that of the usual care group (effect size^a=0.39) The CBT intervention was not associated with significant improvements in other outcomes (anxiety, life space, self-efficacy)
Jalali et al^Citation113 RCT	60 adults aged 20–40 with late blindness	N=30: REBT (a type of cognitive therapy focused on changing irrational beliefs)	N=30: Unspecified	Irrational beliefs (IBT) Psychological well-being (DASS-21) Self-esteem (ESEI)	Participants receiving REBT reported significant reductions in irrational beliefs (effect size^a=2.0), depression (effect size^a=3.2), anxiety (effect size^a=2.3), and stress (effect size^a=2.7) and improvements in self-esteem (effect size^a=1.9), while these same changes were not observed in the control group The positive effects of REBT were maintained 1 month after intervention end

Notes: ^aCohen’s d estimate of effect size where small=0.20, medium=0.50 and large=0.80.

Abbreviations: AMD, age-related macular degeneration; BA+LVR, behavioral activation + low vision rehabilitation; BADS, Behavioral Activation for Depression Scale; CBT, cognitive behavioral therapy; CDS, Chronic Disease Score; DASS-21, Depression, Anxiety, Stress Scale – 21 item; DMSES, Diabetes Self-Care Self-Efficacy Scale; ESEI, Eysenck’s Self Esteem Inventory; GAD-7, Generalized Anxiety Disorder inventory; IBT, Jones Irrational Beliefs Questionnaire; LSA, Life-Space Assessment; MOS-6, Medical Outcomes Study-6; NEI-VFQ, National Eye Institute Visual Function Questionnaire; NEO-PI-R, Revised Neuroticism, Extroversion, Openness Five Factor Inventory; PHQ-9, PHQ-9 Patient Heath; REBT, rational emotive behavior therapy; ST+LVR, supportive therapy + low vision rehabilitation.

Table 5 Stepped Care Interventions

Study	Sample	Intervention	Control	Outcomes Assessed	Main Findings
Van der Aa et al^Citation157 RCT	265 adults aged 50+ with visual impairment, decimal visual acuity of ≤0.3 and/or a visual field of ≤30°, and subthreshold depression and/or anxiety (≥8 on the (HADS-A) (CES-D)	N=131: Four consecutive steps, each approximately 3 months: watchful waiting, guided self-help based on CBT, PST, and referral to the general practitioner. Participants with increased symptoms of depression and/or anxiety (score of ≥8 on the HADS-A and/or ≥16 on the CES-D) were moved to the next step.	N=134: Usual care (outpatient low vision rehabilitation care and/or care that was provided by other healthcare providers)	Depressive disorder diagnosis Depressive symptoms (CES-D) Anxiety symptoms (HADS-A) Vision-related quality-of-life (LVQoL) Adaptation to vision loss (AVL) Health-related quality-of-life (EQ-5D) Covariates: Sociodemographic factors, acuity, psychiatric history	29% of participants in the stepped care group and 46% in the usual care group developed a depressive and/or anxiety disorder over the 24-month follow-up; stepped care participants were significantly less likely to develop a depressive and/or anxiety disorder (P=0.01) Participants receiving stepped care had greater improvements in depressive (P=0.02) and anxiety (P=0.04) symptoms and vision-related quality-of-life (P=0.02) relative to the control group Approximately 25–30% of participants in the stepped care group that qualified for guided self-help or PST were either non-compliant or not fully adherent and reported finding the steps to be unnecessary or too burdensome

Abbreviations: AVL, Adaptation to Vision Loss scale; CBT, cognitive behavioral therapy; CES-D, Center for Epidemiological Studies Depression Scale; EQ-5D, EuroQol Five Dimensions Questionnaire; HADS-A, Hospital Anxiety and Depression Scale–Anxiety Subscale; LVQoL, low vision quality-of-life; PST, problem-solving treatment.

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