Title: A Literature Review of Depression and Macular Degeneration
Authors: Isabella Stoakes OMS3, Robert Bhatia OMS3, Albert Brady M.D.
Introduction
The prevalence of depression among people with Age-Related Macular Degeneration (AMD) is approximated at 30%. Many ophthalmologists are aware of this strong correlation between AMD and depression, but there is no current screening in place. Patients with AMD are seen for their ocular symptoms and their depression can go unscreened and untreated, commonly worsening their visual symptoms. The purpose of this review is to highlight how depression screenings in AMD patients can improve perceived vision and quality of life.
Methods
Publications included in this literature review were primarily located via search of Cochrane, PubMed, MedlinePlus, and EBSCOHost databases. Key search terms included “macular degeneration”, “depression”, “depression screening”, “depression in ophthalmologic conditions” and “geriatrics and mental health”, with additional requirements for a publication date between 2000 and 2022. Date was extracted from eligible articles on: “depression and macular degeneration”, “depression screenings”, and “ophthalmology screenings for mental health”. 17 articles met the inclusion criteria and were selected for use.
Results
A prospective cohort found that declining depression in participants with AMD predicted function far above what vision loss normally accounts for. AMD participants with depression were 8.3x more likely to experience a significant decline in function even when the effects of visual acuity were controlled. A randomized controlled trial from 2007 studied bilateral neovascular AMD participants that were randomized to either Problem Solving Therapy (PST) or a usual-care control condition. After just 2 months, only 12% of the PST participants were depressed compared to 23% in the control group. Recently, a 2021 cohort study found a strong correlation between the Geriatric Depression Scale (GDS) and central retinal thickness (CRT), average macular thickness (AT), and retinal nerve fiber layer thickness (RNFL).
Discussion
There is no current screening for depression in standard AMD exams. Studies have shown that if depression is treated in patients with AMD, it can prevent premature vision loss as well as quality of life decline. Improvements can be made to include the addition of depression screening to complement what is included in an AMD initial exam and follow-up. The screening should be a part of the patient’s chart and the physician can use the findings to make appropriate referrals through the Smartsight initiative, whether that be to a low-vision program or a behavioral health specialist. Many articles have supported that early detection, prevention and treatment can lower both the rate of depression but also the intensity of visual symptoms.
Very interesting presentation! As one of the judges for this project, I was wondering if there are hypotheses as to the mechanism of premature vision loss in those that are depressed and also whether there might just be a direct link between those losing sight quickly and those that are more likely to be depressed – thus looking for depression might be selecting those already losing sight quickly. Thanks!
Thank you for your question Dr. Rhodes! Unfortunately, many of the articles’ hypotheses follow a “which came first, the chicken or the egg” phenomenon, so pinpointing a direct link between rapid vision loss and depression is tricky. Some articles hypothesize that once a patient receives the diagnoses of AMD, they tend to show more depressive behaviors. Thus, due to the disease’s inevitable progression to blindness, they fall deeper into depression with their respective decline in visual acuity and ability to perform activities of daily living. Others hypothesize that depression itself actually worsens subjective visual acuity in patients with AMD. It seems that there is no definitive anatomical mechanism for those with a more rapid decline but that of a functional mechanism. This helps to support our aim to highlight that if depression is screened for and then treated, excess disability associated with this type of vision loss can hopefully be reduced in an already vulnerable population.
Great presentation, Student Dr. Stoakes. I have been assigned as one of the judges for your project. As someone with a parent recently diagnosed with macular degeneration, what can you recommend we as family members do to support people with this incurable and life-altering condition?
Thank you for your question Dr. Briggs Early! It takes a village to support our family, friends and patients with AMD due to the complexity and life-changing caliber of the disease. The inevitable decline in visual acuity can leave those we care about frustrated with AMD’s incurability. From our dive into this prevalent cycle of depression and visual decline, it seems the best ways family members can show support to their loved-one with AMD is to be a part of their journey; letting them know they are not alone, helping them to navigate their environment as their vision changes, and empowering them through the lifetime of ophthalmologist appointments, low vision therapy, and hopefully primary care appointments that address possible compounding mental health changes.
Great, thanks so much for your presentation and your thorough response to my question.
Thanks for this presentation, I am one of your judges. I could imagine that depression may also be associated with other age-related eye disorders. Aside from providing depression screening for patients with AMD, does your team have any recommendations for ophthalmologists working with geriatric populations suffering from vision loss?
Thank you for your question Dr. Mapes! In our research we did find additional articles that also highlighted the correlation between depression and Fuch’s Corneal Dystrophy, glaucoma, Dry Eye Disease, and even cataracts in the geriatric population. While our data suggests that a depression screening (likely the Geriatric Depression Scale or PHQ-9) with the appropriate referrals and coordination of care with PCP/Behavioral Health could help decrease the excess disability in the geriatric population, additional improvements could be made. Ophthalmologists could consider working closely with low vision specialists or even have a low vision specialist in-house to empower and assist patients with performing activities of daily living as their vision will inevitably decline regardless of mental health. We also recognize that this is not always an easy task, especially in rural and underserved areas. Further research could be done to determine ease and efficacy of referrals and low vision therapy in these areas.