Addressing Depression in Vision Loss Patients

NOVEMBER 11, 2017
Kevin Kunzmann
John D. Shepherd, MDJohn D. Shepherd, MD
It took his own bout with a chronic condition for John D. Shepherd, MD, to understand depression in patients.

Shepherd, the Director of the Weigel Williamson Center for Visual Rehabilition, presented a lecture on depression in ophthalmic patients at the 121st Annual Meeting of the American Academy of Ophthalmology (AAO 2017) in New Orleans, LA.

He began the lecture with an anecdote. Shepherd developed severe back pain years ago, which was only worsened when he injured his right knee and thus altered his walking form. Over several years, he was treated by several doctors, received multiple treatment regimens, underwent 2 surgical operations, and took months of physical therapy.

All the while, Shepherd found that his doctors were “woefully insensitive” to patients living with chronic pain. He eventually attempted suicide, then was treated as a patient with major depression.

“I will tell you that nowhere along the line was there ever a physician or health care professional that talked to me about how I can live with this,” Shepherd said.

Shepherd came under the realization that his patients with age-related macular degeneration (AMD) were showing the same depressive symptoms he once did. Living with constant blurred vision and an impairment from normal lives, Shepherd’s patients never expressed their problems until he bothered to ask about them.

“I really didn’t do much better than the doctors did with me,” Shepherd said. “They don’t offer encouragement, they don’t offer hope.”

Depression is an investigated trend in the ophthalmic patient populations. In 2 studies observing depression in AMD patients, researchers reported that there is a 30% prevalence of depression in the low vision patient population.

If that rate is accurate, then such patients are 3 times as likely to suffer from depression than the general population, Shepherd said.

Another study, the Depression in Visual Impairment Trial (DEPVIT) found that 43% of a 1,000-plus patient pool had significant depressive symptoms. Of that group, 74.8% were not being treated for depression.

Shepherd pointed to particular setbacks ophthalmologists face in diagnosing depression, such as their lack of skill in diagnosing psychological illness, or the impression that depression is a “normal part of aging.”

“I think we have to look at these reasons and not justify our behavior with them,” Shepherd said. “I think we have to change our thinking to be able to address the needs of our patients.”

Treatments available for patients with depression include psychiatric medications, professional counseling, and low vision rehabilitation (LVR) in susceptible patients. One LVR study, the Low Vision Depression Prevention Trial (VITAL), found LVR’s efficacy in depressive disorder prevention in AMD patients when compared to placebo psychological treatment.

LVR, however, is still used on a limited basis by clinicians, Shepherd said. With visual impairment expected to double by 2050, he advised doctors become more familiarized with the therapy — as well as the subsets of vision loss patients susceptible to depression.

Shepherd pointed to chronic eye disease patients with progressive vision loss, patients with any difficulty in daily tasks, and patients with vision-loss eye diseases for which there are no medical or surgical options for treatment.

He also advised an implementation of positive communication, pointing back to his difficulties with chronic pain physicians years ago. Ophthalmologists can stress what can be done for patients, as opposed to what cannot be done, and express language that focuses on quality-of-life improvement.

“Remember that listening can never hurt, but words can,” Shepherd said. “Avoid negative comments that just don’t offer hope or encouragement — say things that are positive.”

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