Not surprisingly, when a person with age-related macular degeneration has
already lost vision in one eye and starts to lose it in the other as well, he
or she is at high risk for depression. However, a new therapy can prevent
depression in such individuals, at least over the short term.
So reported Barry Rovner, M.D., a professor of psychiatry at Jefferson
Hospital for Neuroscience in Philadelphia, and colleagues in the August
Archives of General Psychiatry.
The new therapy is called problem-solving treatment (PST). The goal is to
teach persons with age-related macular degeneration how to compensate for
their poor vision and thereby make it possible for them to continue pursuing
activities that are important to them.
Rovner and his colleagues explored the possible value of PST in preventing
depression in 206 persons who had already lost vision in one eye due to
age-related macular degeneration and who had recently been found to have the
condition in their other eye as well. None of the subjects was depressed at
the start of the study. Half the subjects were randomly assigned to usual care
and the other half to PST.
Those assigned to PST received six therapy sessions over an eight-week
period in their homes. During these sessions, they were asked to carefully
define their visual challenges, to break them down into smaller, more
manageable parts, and to brainstorm possible solutions. Solutions might be
getting better lighting, reading large-print books, listening to books on
tape, using magnifiers, using brightly colored tape to mark stove settings,
enlisting the help of others, or being evaluated by a low-vision
rehabilitation specialist. They were urged to pursue one or more of these
From the start of the study to six months later, Rovner and his colleagues
followed subjects in both groups to determine whether any became
At the two-month follow-up, only 12 percent of the PST group had developed
depression, compared with 23 percent of the control group—a significant
difference. Moreover, the reason why the PST group had a lower level of
depression appeared to be because PST helped them to stay engaged in life
despite visual impairment.
This positive effect, however, was no longer evident at the six-month
follow-up. Although Rovner and his colleagues were disappointed by this
result, they were still heartened by the two-month finding. Furthermore, they
believe that if booster PST sessions had been offered to PST subjects after
the active-treatment phase, it might well have warded off depression for a
longer period. "We are in the process of designing a study that will
include booster sessions," Rovner told Psychiatric News.
Meanwhile, if persons with age-related macular degeneration want PST
treatment, how can they get it? "Because mental health and eye care are
not integrated, it is necessary to go through a mental health provider
directly," Rovner said. "Most older people will not do that. A
very reasonable alternative is to see a low-vision ophthalmologist or
optometrist, some of whom work with occupational therapists. They can improve
function using some of the strategies of PST and thereby possibly prevent
depression. We're now preparing an intervention that would train occupational
therapists, working with optometrists, to use PST to structure their
interventions and directly deal with depressive symptoms."
Because it is relatively generic, PST could also be applied to prevent
depression in individuals with other kinds of medical illnesses, Rovner and
his colleagues suggested. In fact, one of them—Mark Hegel, Ph.D., of
Dartmouth Medical Center—is using PST to try to prevent depression in
women with breast cancer.
In an accompanying editorial, Charles Reynolds III, M.D., a professor of
geriatric psychiatry at the University of Pittsburgh, and colleagues praised
the study by Rovner and his team because "it breaks new ground."
They noted that few clinical trials have been undertaken to determine whether
depression can be prevented in middle-aged and older adults with medical
The study by Rovner and his group is also another indication that
prevention may finally be coming of age in psychiatry. During the past decade,
for example, resilience has garnered increasing attention from psychiatric
researchers, an Air Force suicide-prevention program has been found effective,
a cognitive-behavioral intervention delivered via the Internet has been found
capable of preventing eating disorders, and a phone intervention has kept
primary-care patients on the brink of a clinical depression from developing
The study was funded by the National Institute of Mental Health, National
Eye Institute, and Farber Institute for Neurosciences of Thomas Jefferson
An abstract of "Preventing Depression in Age-Related Macular
Degeneration" is posted at<http://archpsyc.ama-assn.org/cgi/content/abstract/64/8/886>.▪