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  • 1. ORIGINAL ARTICLE Detection of Depression in Patients with Low Vision Gwyneth Rees*, Eva K. Fenwick† , Jill E. Keeffe*, David Mellor*, and Ecosse L. Lamoureux* ABSTRACT Purpose. Depression is common in people with vision impairment and further reduces levels of functioning independent of vision loss. However, depression most often remains undetected and untreated this group. Eye health professionals (EHPs) (ophthalmic nurses, ophthalmologists, optometrists, and orthoptists) and rehabilitation workers (RWs) may be able to play a role in detecting depression. This study aimed to identify current practice and investigate factors associated with depression management strategies. Methods. A self-administered cross-sectional survey of EHPs and RWs assessed current practice including confidence in working with depressed people with vision impairment; barriers to recognition, assessment, and management of depression; beliefs about the consequences, duration, and efficacy of treatment for depression in individuals with vision impariment. Results. Ninety-four participants aged 23 to 69 years took part. Thirty-seven participants (39.8%) stated that they attempted to identify depression as part of patient management, with RWs significantly more likely to do so (n ϭ 17, 60.7%) than EHPs (n ϭ 20, 30.8%; p ϭ 0.007). Intention to identify depression was not associated with sociodemo- graphic factors, professional experience in eye care services, or the length and number of patient consultations, but a significant relationship was found for confidence, barriers, and beliefs about depression (p Ͻ 0.05). No consistent depression management strategy emerged and a range of barriers were highlighted. Conclusions. Training programs are needed to provide EHPs and RWs with the skills and resources to address depression in people with vision loss under their care and to support the development of procedures by which concerns about depression can be identified objectively, documented, and included as part of a referral to appropriate services. (Optom Vis Sci 2009;86:1328–1336) Key Words: depression, professional development, barriers, training needs T he emotional consequences of vision loss have been well described, with rates of depression estimated to be 2 to 5 times greater in older adults with low vision than in sighted individuals of similar age.1–5 Depression has been shown to exac- erbate disability and further reduce levels of functioning in this group independent of vision loss, by reducing motivation, initia- tive, and resiliency.6,7 Even minimal depressive symptoms, which do not meet the diagnostic criteria, are associated with functional decline not accounted for by eye disease or other medical prob- lems.8 The diagnostic criteria for depression are well established, and good screening tools exist. Effective medicinal and therapeutic regimes are also available to treat depression, and treatment is most effective when implemented early. Despite this, depres- sion often remains undetected and therefore untreated in peo- ple with vision loss.6,9,10 General practitioners (GPs) play a central role in detecting and managing depression in primary care settings. However, research has identified a range of patient, doctor, and practice factors that present barriers to detection and management of depression in primary care.11–13 The most prominent ones include practitioners’ attitudes to depression, low confidence in assessing depression, and insufficient access to mental health resources.11–13 Communica- tion problems may make depression even more difficult to detect in older adults compared with younger adults. Specifically, GPs are less likely to ask older adults about their psychological and social wellbeing, and older adults are less likely to raise these issues.14 Vision impairment is yet another barrier to effective doctor–patient communication.15 Indeed, patients with vision impairment and depression have been identified as a group in which depression is least likely to be recognized by their GP.16 Eye health professionals (EHPs), including ophthalmic nurses, ophthalmologists, optometrists, orthoptists, and rehabilitation work- ers (RWs), are key care providers for people with vision impairment who could play a role in detecting depression. In the recently pub- lished clinical guidelines for managing depression, the National Insti- *PhD † MSc Centre for Eye Research Australia, the Royal Victorian Eye and Ear Hospital, Uni- versity of Melbourne, Department of Opthalmology (GR, EKF, JEK, ELL), and School of Psychology, Deakin University (DM), Melbourne, Victoria, Australia. 1040-5488/09/8612-1328/0 VOL. 86, NO. 12, PP. 1328–1336 OPTOMETRY AND VISION SCIENCE Copyright © 2009 American Academy of Optometry Optometry and Vision Science, Vol. 86, No. 12, December 2009
  • 2. tute of Clinical Excellence recommended that screening should take place in primary care and general hospitals for those at high risk of depression, including patients with an illness causing disability.17 Studies from other primary and tertiary health care fields, including oncology, heart disease, diabetes, maternal health, and stroke, have described the processes by which depression is managed in these set- tings and barriers to care.18–24 However, no quantitative study to date has focused on care providers for people with vision impairment, and itisunclearhowEHPsorRWsrecognizeandrespondtodepressionin their patients. In addition, EHPs and RWs are diverse groups with different professional backgrounds and work settings, and they may also have access to different resources, hold different views, and expe- rience different barriers. This study therefore aimed to identify current practice of eye care professionals and to investigate factors associated with their responses to depression. We also investigated the barriers experi- enced by the different professional groups, and their training preferences to determine how best to support practitioners in identifying and responding to depression. METHODS Participants and Recruitment The study was a cross-sectional survey of EHPs and RWs across the Australian state of Victoria. Ethical approval was received from the Human Research and Ethics Committee of the Royal Victo- rian Eye and Ear Hospital, and all participants gave signed consent. Following consultations on appropriate recruitment strategies, questionnaires were distributed to EHPs through their profes- sional organizations and to RWs through their rehabilitation agencies. Four weeks after the initial questionnaire distribution, reminder packs were sent out to nonresponders. Measures Background Sociodemographics and details of professional background, training, and current work were recorded in the first section of the questionnaire. Current Practice Participants were asked to outline the current resources available to manage depression and to rate the likelihood of undertaking nine actions if they suspect a patient to be depressed (e.g., “Provide education and information about depression”) using a 4-point scale (“definitely unlikely” to “definitely likely”). Confidence in Recognizing and Responding to Depression in People with Vision Impairment Adapted from an existing measure to assess confidence in work- ing with elderly people with depression.25 Participants respond to 14 items on a 4-point scale (“not confident” to “very confident”). Summed scores range from 14 to 56 with high scores representing greater confidence in working with depressed patients. Barriers to Recognition, Assessment, and Management of Depression Adapted from an existing measure to assess barriers to work- ing with depressed elderly patients.25 The scale includes 13 items, which are rated on a 4-point scale (“strongly disagree” to “strongly agree”). Summed scores range from 13 to 52 with high scores representing greater barriers to working with pa- tients with depression. Training Needs and Future Practice A 10 item study-specific measure to assess (i) interest in improving knowledge (signs and symptoms of depression and services and resources available), (ii) use of tools (guidelines and screening tools), (iii) interest in developing skills (communica- tion skills and identifying depression), and (iv) interest in be- havior change (attendance at professional development, discuss emotional issues, refer patients, and educate patients). Partici- pants rate each item on a 4-point scale (“strongly disagree” to “strongly agree”). Beliefs about Depression in Individuals with Vision Impairment Beliefs about depression in individuals with vision impari- ment were assessed using an adaptation of the Illness Percep- tions Questionnaire (Revised).26 Beliefs about the conse- quences (six items) (e.g., “depression is a serious condition for a person with vision impariment”), timeline (six items) (e.g., “de- pression will last a long time for a person with vision impair- ment”), and efficacy of treatment for depression (five items) (e.g., “treatment can control depression in a person with vision impairment”) were assessed using a 5-point scale (“strongly disagree” to “strongly agree”). Scores ranged from 5 to 30 for consequences and timeline and 2 to 25 for treatment control. High scores represent beliefs that depression is serious, long- lasting condition and that treatment is effective. Analysis Descriptive statistics were used to describe current practice and barriers reported. Univariate analysis using t tests, analysis of variance, andcorrelationsdeterminedfactorsassociatedwithcurrentdepression management strategies. Analysis of variance and post hoc tests were used to identify differences between professional groups. RESULTS Response Rates Six hundred sixty-six questionnaires were sent out to optome- trists (n ϭ 82), ophthalmic nurses (n ϭ 97), orthoptists (n ϭ 205), ophthalmologists (n ϭ 189), and RWs (n ϭ 93). A total of 94 questionnaires were returned, giving a final response rate of 14.1%. Responses rates were significantly higher for RWs (n ϭ 28, 30.1%) than the EHPs: optometrists (n ϭ 12, 14.6%); ophthalmic nurses (n ϭ 12, 12.4%); orthoptists (n ϭ 22, 10.7%); ophthalmologists (n ϭ 20, 10.6%) [␹2 ϭ 24.33, degrees of freedom (df) ϭ 4, p Ͻ Depression in Patients with Low Vision—Rees et al. 1329 Optometry and Vision Science, Vol. 86, No. 12, December 2009
  • 3. 0.001]. Reminders had a substantial impact on the overall re- sponse rate, with 34.0% of questionnaire returns coming after the reminder. Participants Tables 1 and 2 describe the participants. The sample was largely female aged between 23 and 69 years. The length of time the participants had been in their current role, or eye care services in general, ranged from less than a year to more than 35 years. Work settings included public hospital, private practice, community set- tings, or combinations of these and varied across professional groups. The number of patients with vision impairment seen each week ranged from 1 to 120, and the time spent with each patient also varied considerably (1 to 200 min). Professional groups dif- fered on the number of people with vision impairment reported to be seen each week (F4,87 ϭ 7.612, p Ͻ 0.001) and the amount of time spent with each patient (F4,87 ϭ 43.239, p Ͻ 0.001). Oph- thalmic nurses and ophthalmologists saw significantly more pa- tients with vision impairment than did optometrists or RWs (p Ͻ 0.05). However, RWs had significantly longer consultations with patients than any other group (p Ͻ 0.001), and optometrists had significantly longer consultations than ophthalmologists (p ϭ 0.005). Less than 20% (n ϭ 18) of participants reported having ever received any training in depression. Although few participants (n ϭ 15, 16%) reported having personally experienced depression, more than 70% reported knowing family or friends who had. Current Practice Identification of Depression Overall, 39.8% (n ϭ 37) of participants stated that they at- tempted to identify depression as part of patient management, with RWs significantly more likely to do so (n ϭ 17, 60.7%) than EHPs (n ϭ 20 30.8%) (␹2 ϭ 7.325, df ϭ 1, p ϭ 0.007). Socio- demographic and work-related factors including duration in eye care services and consultation times were not associated with in- tention to identify depression, but confidence, barriers, and beliefs about depression were associated (p Ͻ 0.05). Compared with those who did not attempt to detect depression, participants who aimed to identify depression were more confident (mean ϭ 37.89, SD 7.11 vs. mean ϭ 30.12, SD 7.66; t ϭ 4.772, df ϭ 85, p Ͻ 0.001), reported fewer barriers (mean ϭ 27.09, SD 7.47 vs. mean ϭ 33.63, SD ϭ 7.05; t ϭ Ϫ4.034, df ϭ 80, p Ͻ 0.001), and believed depression to hold greater consequences for a person with vision impairment (mean ϭ 26.20, SD 2.92 vs. mean ϭ 24.59, SD 3.07; t ϭ 2.48, df ϭ 89, p ϭ 0.015). Management of Patients Who may be Depressed The resources available to support patient management varied according to work setting. The majority of participants working in public hospitals stated that they had access to a social worker (n ϭ 29, 76.3%), RWs had access to a psychologist (n ϭ 18, 60%) and counselor (n ϭ 16, 53.3%), and were more likely to refer to these services than EHPs (␹2 ϭ 34.813, df ϭ 4, p Ͻ 0.000). Resources available in private practice were limited, with more than a third (n ϭ 16, 38.1%) of participants working in this setting reporting no onsite resources. Ophthalmologists were most likely to report TABLE 1. Sociodemographic, work, and personal characteristics of the 94 participants Age (yr) Mean 42.1 Range 23.3–69.4 Sex, n (%) Female 71 (75.5) Male 23 (24.5) Time in current role (yr) Mean 8.5 Range 0.4–37 Time in eye care services (yr) Mean 14.6 Range 0.4–42 Previous depression training, n (%) Yes 18 (19.1) No 76 (80.9) Personal experience of depression,a n (%) Yes 15 (16.0) No 65 (69.1) Family or friends’ experience of depression,a n (%) Yes 66 (70.2) No 27 (28.7) a Percentage does not total 100 due to missing data. TABLE 2. Work setting and number and duration of consultations with patients with vision impairment for each professional group Professional group Most common work setting No. patients with vision impairment seen each week, mean (SD) Average time spent with each patient (min), mean (SD) Ophthalmic nurse (n ϭ 12) Public hospital (n ϭ 11, 91.7%) 29.7 (32.3) 20.5 (34.05) Optometrist (n ϭ 12) Private practice (n ϭ 7, 58.3%) 5.08 (8.9) 46.4 (15.6) Ophthalmologist (consultant) (n ϭ 20) Combination of private practice and public hospital (n ϭ 13, 65%) 37.9 (33.8) 13.0 (3.6) Orthoptist (n ϭ 22) Private practice (n ϭ 8, 36.4%) 20.2 (17.7) 23.6 (26.7) Rehabilitation worker (n ϭ 28) Rehabilitation agency (n ϭ 27, 96.7%) 8.3 (4.3) 98.2 (32.6) 1330 Depression in Patients with Low Vision—Rees et al. Optometry and Vision Science, Vol. 86, No. 12, December 2009
  • 4. that they had access to a psychiatrist both in public setting (n ϭ 8, 53.3%) and private practice (n ϭ 7, 38.9%). Table 3 outlines the depression management strategies and factors associated with each strategy. The most common actions were referral to a GP (n ϭ 75, 79.8%) and referral to rehabilitation services (n ϭ 71, 75.5%). Only a quarter (24.5%) stated that they were likely to provide information and education about depression. Level of confidence in managing depressed patients and barriers to management were consistently significantly associated with a range of actions (p Ͻ 0.05). In addition, participants’ beliefs about depression were also associated with specific actions. For example, those with greater belief in the effectiveness of treatment for depression in pa- TABLE 3. Depression management strategies and associated sociodemographic, work, and psychosocial characteristics Depression management strategies Total % of participants likely to use this strategy (n ϭ 94) Factors positively associated with strategy Factors negatively associated with strategy Professional group differences GP referral 79.8 — — 1 Ophthalmologist compared to RWa (F4,88 ϭ 2.756a ) Vision rehabilitation referral 75.5 — — — Discussion of feelings 74.5 Confidence (r ϭ 0.589,b n ϭ 86) and beliefs about consequences (r ϭ 0.340,b n ϭ 91) Barriers (r ϭ Ϫ0.525,b n ϭ 81) No. VIP per wk (r ϭ Ϫ0.225,a n ϭ 92) Duration in current position (r ϭ Ϫ0.210,a n ϭ 92) — Referral to a self-help or support group 50.0 Confidence (r ϭ 0.330,c n ϭ 86) and depression training (yes) (t ϭ 3.588,b df ϭ 91) Barriers (r ϭ Ϫ0.245,a n ϭ 81) 1 RW compared with orthoptista (F4,88 ϭ 2.970a ) Referral to a mental health service such as counseling or a psychologist 35.1 Time per VIP (r ϭ 0.428,b n ϭ 89) Confidence (r ϭ 0.317,c n ϭ 84) Beliefs about treatment (r ϭ 0.267,a n ϭ 90) Depression training (yes) (t ϭ 2.784,c df ϭ 89) Barriers (r ϭ Ϫ0.489,b n ϭ 79) No. VIP per week (r ϭ Ϫ0.221,a n ϭ 89) 1 RW compared with ophthalmic nurse,b ophthalmologist,b optometrist,b or orthoptistb (F4,86 ϭ 12.668b ) Referral to another health professional 35.1 Confidence (r ϭ 0.255,a n ϭ 78) Beliefs about treatment (r ϭ 0.237,a n ϭ 82) — 1 Ophthalmic nurses compared with ophthalmologistsc or orthoptista (F4,78 ϭ 4.190c ) Provide information and education about depression 24.5 Confidence (r ϭ 0.417,b n ϭ 86) Depression training (yes) (t ϭ 2.878,c df 91) Barriers (r ϭ Ϫ0.440,b n ϭ 81) No significant post hoc test results (F4,88 ϭ 2.914a ) Avoid discussing patients’ feelings 14.9 Barriers (r ϭ 0.430,b n ϭ 80) Time in current position (r ϭ Ϫ0.265,a n ϭ 91) Confidence (r ϭ Ϫ0.535,b n ϭ 85) Beliefs about consequences (r ϭ Ϫ0.335,b n ϭ 90) — Use a depression screening questionnaire 4.3 Beliefs about treatment (r ϭ 0.219,a n ϭ 91). Barriers (r ϭ Ϫ0.275,a n ϭ 80) — Confidence (r ϭ 0.217,a n ϭ 85) The following Likert scale was used: 1, “definitely unlikely”; 2, “probably unlikely”; 3, “probably likely”; 4, “efinitely likely.” Post hoc comparisons for professional group differences were computed using Tukey’s honestly significant difference (HSD) test. Significant correlations or group differences are noted using a p Յ 0.05, b p Յ 0.001, and c p Յ 0.01. Depression in Patients with Low Vision—Rees et al. 1331 Optometry and Vision Science, Vol. 86, No. 12, December 2009
  • 5. tients with vision impairment were more likely to refer to a mental health service (p ϭ 0.011) or other health professionals (p ϭ 0.032) and use a depression screening tool (p ϭ 0.037). Few work-related factors were associated with referral strategies, except referral to a mental health service was positively associated with consultation time (p Ͻ 0.001), and negatively associated with the number of patients seen each week (p ϭ 0.046). Talking to patients about their feelings was negatively associated with the number of pa- tients seen each week (p ϭ 0.031) and duration in current role (p ϭ 0.044). Those participants who had received some form of training in depression previously were more likely to use a range of strategies including referral to self-help/support group, mental health service, and providing information and education (all p Ͻ 0.05). Barriers to Patient Management Table 4 outlines the barriers to recognizing and responding to depression reported by participants. Common barriers included absence of standard procedures to follow (n ϭ 64, 68.1%); limited knowledge about depression (n ϭ 63, 67%); and lack of training in depression (n ϭ 59, 62.8%). Time and workload were found to be a greater barrier for ophthalmic nurses, ophthalmologists, and or- thoptists than RWs (all p values Յ0.002). For ophthalmologists and orthoptists, the focus of their role on eye health was a greater barrier than for RWs (all p values Ͻ0.05). Knowledge about what to do when a patient may be depressed was a greater barrier for orthop- tists compared with RWs (p ϭ 0.007). Ophthalmic nurses reported that the environment in which they work was a greater barrier to holding private discussions with patients compared with all other groups (all p values Ͻ0.05), and their lack of ongoing contact with patients was a greater barrier compared with RWs (p Ͻ0.001), or- thoptists, or ophthalmologists (all p values Ͻ0.05). Training Needs and Future Preferences The majority of participants were enthusiastic about training opportunities (Table 5). More than 90% of participants like to be able to refer patients to appropriate services and improve their knowledge of services and treatment options. More than 80% of participants indicated that they would like to have more informa- tion about signs and symptoms of depression, to be able to identify depression more easily, and to enhance their communication skills. Compared with all other groups, ophthalmologists were least likely towanttoattendaprofessionaldevelopmenteventtoimproveknowl- edge or skills for managing patients with depression (p Ͻ 0.05). Op- tometrists had a stronger preference for information about the signs and symptoms of depression than ophthalmologists or RWs (p Ͻ 0.05). Ophthalmic nurses were more keen to discuss patients’ feelings than ophthalmologists or RWs (p Ͻ 0.001) and to use a depression screeningtoolthanophthalmologists,orthoptists,orRWs(pϽ0.05). DISCUSSION Despite the high prevalence of depression in people with vision impairment, little is known about how professionals working with this patient group manage depression. In this study, we highlight that active identification of depression is not a routine part of patient care for EHPs, although it occurs to some extent in reha- bilitation settings. Work-related factors, such as number of pa- tients seen per week or consultation duration, were not related to an interest in or intention to screen patients for depression. In- stead, participants’ confidence, barriers, and beliefs about the con- sequences of depression and treatment efficacy were significantly associated with likelihood of identifying and responding to depres- sion. This is promising because work factors may not be easily amenable to change, whereas level of confidence and beliefs can be effectively targeted by training programs.27–30 Our data indicate that if participants suspect depression in their patients, they respond with a variety of strategies, although they are often limited by resources available to them, particularly EHPs working in private settings. Referrals to a GP or vision rehabilita- tion service were most common and seemed to be used often by all groups. Both pathways hold promise. In Australia, GPs have access to Medicare-funded psychological services for depression. Vision rehabilitation services can also include counseling services, and our results also suggest that RWs may have more time and capacity within their role to focus on emotional health. However, there are two major caveats in these pathways. First, it is unclear whether patients will use the referral. A recent study of a rehabilitation service link to a public eye hospital in Victoria, Australia, found that less than half of those referred attended.31 Patients with de- pressive symptoms are even less likely to follow such a referral through, and, if they do, research has found that they use fewer rehabilitation services.9 Therefore, it has been suggested that it is necessary to treat depression in people with vision impairment before rehabilitation to improve rehabilitation outcomes.6,32–34 Second, it is unclear whether concerns about depression are dis- cussed with the patient or if these concerns are noted as part of the referral. Our data suggest that it is unlikely that depression is ex- plicitly discussed with the patient. We did not ask in this survey whether participants provided information about their concerns to the patient as part of the referral process, although findings from our focus groups with EHPs suggest that there are no standard systems in place to support this.35 Given the difficulties in identi- fying depression in primary care settings already described, it is likely that depression may remain undetected whether the GP or rehabilitation agencies are not made aware of the concerns of the EHPs. There is a clear opportunity to build on these existing re- ferral strategies by developing procedures by which concerns about depression can be identified objectively, documented, and included as part of the referral and providing resources and skills for EHPs and RWs to address the issue of depression with their patients. It is promising to see that previous training in depression is related to increased likelihood of responding to depression and that participants are enthusiastic about future training opportunities. Participants expressed a strong desire to increase their knowledge of services, treatment options, and referral strategies. This infor- mation should be provided as clear guidelines or procedures suit- able to particular settings. Indeed, training programs should be developed to suit the needs and preferences of different groups. Our results indicate that time and workload issues were most prob- lematic for ophthalmic nurses, ophthalmologists, and orthoptists, who would need quicker strategies suited to the context in which they work. For ophthalmic nurses, in particular, it is important to ensure that strategies are not dependent on ongoing contact and are easily administered in a busy hospital setting. Ophthalmolo- 1332 Depression in Patients with Low Vision—Rees et al. Optometry and Vision Science, Vol. 86, No. 12, December 2009
  • 6. gists were least likely to be interested in training, possibly because of existing knowledge from medical training. However, their sup- port is likely to be critical in the development and implementation of local guidelines and procedures. Currently, Ͻ5% of participants reported to use a screening tool withpatientstheysuspectedtobedepressedalthoughmorethan50%, notably ophthalmic nurses, indicated a desire to do so. A range of screening tools for depression exists and short two-item tools, which havebeenshowntobevalid,36,37 maybeusefulinbusysettings.These tools will be valuable in assisting EHPs and RWs to identify those patients who may benefit further from a more detailed assessment and in providing information to support this referral. TABLE 4. Barriers to depression management reported by each professional group Barriers to working with patients with vision impairment and depression Total % of participants who agreed this was a barrier (n ϭ 94) Mean (SD) ON OPH OPT ORT RW Absence of standard proceduresa 68.1 3.33 (0.65) 2.75 (0.97) 3.00 (0.74) 3.15 (0.93) 2.39 (0.92) F4,87 ϭ 3.508, p ϭ 0.011 Limited knowledge of depressiona 67.0 2.92 (0.90) 2.90 (0.72) 2.75 (0.75) 3.05 (0.81) 2.39 (0.79) F4,88 ϭ 2.498, p ϭ 0.048 Lack of training to know if a patient might be depressed 62.8 2.83 (0.72) 2.65 (0.75) 3.00 (0.85) 2.95 (0.95) 2.54 (0.88) F4,87 ϭ 1.092, p ϭ 0.366 Poor knowledge of what to do if a patient could be depressedb 56.4 2.83 (0.94) 2.60 (0.82) 2.83 (0.84) 2.90 (0.70) 2.04 (0.69) F4,88 ϭ 4.997, p ϭ 0.001 Role limited to eye health rather than emotional wellbeingb 51.1 2.83 (1.12) 2.89 (.99) 2.00 (.85) 2.90 (.70) 2.00 (.94) F4,87 ϭ 5.265, p ϭ 0.001 Patients’ reluctance to discuss how they feela 51.1 3.27 (0.79) 2.85 (0.75) 2.25 (0.87) 2.76 (0.89) 1.75 (0.75) F4,88 ϭ 2.843, p ϭ 0.029 Lack of time to talk with patientsa 50.0 3.27 (0.79) 2.85 (0.75) 2.25 (0.87) 2.76 (0.89) 1.75 (0.75) F4,87 ϭ 10.425, p Ͻ 0.001 No ongoing contact with patients to notice changes in moodb 47.9 3.58 (0.90) 2.55 (0.76) 2.67 (0.99) 2.48 (0.93) 1.96 (0.69) F4,88 ϭ 8.154, p Ͻ 0.001 High workloadb 44.7 3.00 (1.0) 2.75 (0.72) 2.17 (0.84) 2.52 (0.87) 1.79 (0.74) F4,87 ϭ 6.746, p Ͻ 0.001 Work environment is not suitable for private discussions about emotional wellbeingb 35.1 3.33 (0.65) 2.10 (0.91) 1.75 (0.87) 2.33 (0.97) 1.71 (0.81) F4,88 ϭ 8.380, p Ͻ 0.001 Management does not believe that detecting depression is part of work role 31.9 2.33 (0.89) 2.12 (0.93) 1.80 (0.79) 2.33 (0.86) 1.86 (0.97) F4,83 ϭ 1.315, p ϭ 0.271 Need to protect oneself from involvement with patients’ emotional problems 21.3 3.00 (1.0) 2.75 (0.72) 2.17 (0.84) 2.52 (0.87) 1.79 (0.74) F4,88 ϭ 1.062, p ϭ 0.181 Reluctance by management to listen to concerns about depression 11.7 1.75 (0.87) 2.00 (0.89) 1.60 (0.52) 1.65 (0.75) 1.52 (0.89) F4,80 ϭ 0.921, p ϭ 0.456 Post hoc comparisons for professional group differences were computed using Tukey’s honestly significant difference (HSD) test. The following Likert scale was used: 1, “strongly disagree”; 2, “somewhat disagree”; 3, “somewhat agree”; and 4, “strongly agree.” ON, ophthalmic nurses; OPH, ophthalmologists; OPT, optometrists; ORT, orthoptists; RW, rehabilitation worker. Depression in Patients with Low Vision—Rees et al. 1333 Optometry and Vision Science, Vol. 86, No. 12, December 2009
  • 7. Our results suggest that training should be made available to all new and existing staff because time and extent of clinical experi- ence were not related to behavior, and, in fact, our findings indi- cated that staff with greater experience are more likely to avoid discussing patients’ emotional wellbeing. Training should also be delivered in such a way as to enhance knowledge about the signif- icance of consequences of depression and effectiveness of treat- ment, to enhance participants’ confidence and skills in detecting depression, and to assist participants to overcome barriers to re- sponding to depression. This will require active involvement in TABLE 5. Preferences for training and future practice reported by each professional group Training needs and future practice Total % of participants who agreed with this statement (n ϭ 94) Mean (SD) ON OPH OPT ORT RW I would like to be able to refer patients I am concerned about to appropriate services 94.7 3.67 (0.49) 3.60 (0.50) 3.50 (0.91) 3.45 (0.80) 3.54 (0.64) F4,89 ϭ 0.242, p ϭ 0.914 I would like to improve my knowledge and awareness of the services and treatment options for people with depressiona 90.4 3.58 (0.67) 2.75 (0.72) 3.58 (0.67) 3.64 (0.49) 3.32 (0.77) F4,89 ϭ 5.366, p Ͻ 0.001 I would like to be able to identify depression more easily 87.2 3.33 (0.78) 3.00 (0.46) 3.58 (0.67) 3.23 (0.61) 3.14 (0.71) F4,89 ϭ 1.731, p ϭ 0.150 I would like more information about the signs and symptoms of depression in people with vision impairmenta 86.2 3.42 (0.67) 2.65 (0.88) 3.83 (0.39) 3.45 (0.59) 3.11 (0.79) F4,89 ϭ 6.411, p Ͻ 0.001 I would like to enhance my communication skills for working with depressed patientsa 83.0 3.42 (0.79) 2.50 (0.76) 3.42 (0.67) 3.14 (0.83) 3.29 (0.60) F4,89 ϭ 4.991, p ϭ 0.001 I would like guidelines in my workplace for what to do when I suspect someone has depressionb 78.7 3.50 (0.37) 2.63 (0.83) 3.50 (0.67) 3.27 (0.88) 3.21 (0.78) F4,88 ϭ 3.327, p ϭ 0.014 I would like to attend a professional development event to improve my knowledge and skills for managing patients with depressiona 76.6 3.50 (0.67) 2.20 (0.89) 3.50 (0.67) 2.91 (0.92) 3.32 (0.61) F4,89 ϭ 9.121, p Ͻ 0.001 I would like to be able to educate patients and their families about depressionb 64.9 3.17 (0.72) 2.50 (0.83) 3.33 (0.65) 2.82 (0.91) 2.75 (0.79) F4,89 ϭ 2.596, p ϭ 0.042 I would like to discuss patients’ feelings more oftena 58.5 3.42 (0.67) 2.30 (0.92) 2.92 (0.52) 2.68 (0.89) 2.36 (0.56) F4,89 ϭ 5.7544, p Ͻ 0.001 I would like to use a depression screening tool with my patientsc 55.3 3.33 (0.65) 2.40 (0.68) 3.17 (0.72) 2.41 (0.96) 2.50 (0.88) F4,89 ϭ 4.477, p ϭ 0.002 Post hoc comparisons for professional group differences were computed using Tukey’s honestly significant difference (HSD) test. The following Likert scale was used: 1, “strongly disagree”; 2, “somewhat disagree”; 3, “somewhat agree”; and 4, “strongly agree.” Significant differences between groups are noted using a p Յ 0.001, b p Յ 0.05, and c p Յ 0.01. ON, ophthalmic nurses; OPH, ophthalmologists; OPT, optometrists; ORT, orthoptists; RW, rehabilitation worker. 1334 Depression in Patients with Low Vision—Rees et al. Optometry and Vision Science, Vol. 86, No. 12, December 2009
  • 8. training (e.g., group discussions, case studies, and practical experi- ence) in addition to information provision. Training should also be supplemented with the availability of appropriate resources that are suit- ablefordistributiontopatients.Currently,only1⁄4 ofparticipantsprovide information and education about depression to their patients, although there is a strong desire to do so. To our knowledge, this is the first quantitative study to investi- gate how EHPs and RWs manage depression in patients with vision impairment. Despite a detailed consultation process to en- hance recruitment, the response rate for this survey was poor. However, the response rate is similar to other studies on EHPs,38 and the large proportion of female participants also reflects the nature of this profession. Of more concern is that this study is likely to have attracted those with an interest in depression and may therefore portray an optimistic view about current practice and desire for training. We also acknowledge that this study collected only self-reported data and participants’ retrospective recollections of consultations. We attempted prospective data collection in this study by requesting that participants record details of the consul- tations in which they suspected a patient may be depressed. We specifically asked participants to record what had raised their con- cerns about the patients and what actions they took. However, too few forms were returned to be reported (a total of 18). On the basis of our results, we are currently developing a train- ing program for EHPs located at a tertiary eye care hospital. We will evaluate the impact of this training on confidence, perceived barriers, and behavior. Further work is required to determine pa- tients’ reactions to depression screening in eye-care and vision re- habilitation services; preferences for information and care; care pathways following referral; and uptake and outcomes of services. ACKNOWLEDGMENTS We thank all participants who took part and the following bodies who worked with us to design and disseminate the survey: Optometrists Association Aus- tralia Victoria; Australian Ophthalmic Nurses Association; Royal Australian and New Zealand College of Ophthalmologists; Australian Orthoptic Board; Vision Australia; and Guide Dogs Victoria. This work was supported by beyondblue: the national depression initiative. Received June 17, 2009; accepted August 6, 2009. REFERENCES 1. Burmedi D, Becker S, Heyl V, Wahl HW, Himmelsbach I. Emo- tional and social consequences of age-related low vision. Visual Im- pair Res 2002;4:47–71. 2. Evans JR, Fletcher AE, Wormald RP. Depression and anxiety in visually impaired older people. 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  • 9. pact of communication skills training: results of a 12-month follow- up. Br J Cancer 2003;89:1445–9. 30. Mellor D, Russo S, McCabe MP, Davison TE, George K. Depression training program for caregivers of elderly care recipients: implemen- tation and qualitative evaluation. J Gerontol Nurs 2008;34:8–15. 31. O’ConnorPM,MuLC,KeeffeJE.Accessandutilizationofanewlow-vision rehabilitation service. Clin Experiment Ophthalmol 2008;36:547–52. 32. Crews JE, Jones GC, Kim JH. Double jeopardy: the effects of comor- bid conditions among older people with vision loss. J Visual Impair Blind 2006;100:824–48. 33. Rovner BW, Zisselman PM, Shmuely-Dulitzki Y. Depression and disability in older people with impaired vision: a follow-up study. J Am Geriatr Soc 1996;44:181–4. 34. HorowitzA,ReinhardtJP,BoernerK.Theeffectofrehabilitationondepres- sion among visually disabled older adults. Aging Ment Health 2005;9: 563–70. 35. Fenwick EK, Lamoureux EL, Keeffe JE, Mellor D, Rees G. Detection and management of depression in patients with vision impairment. Optom Vis Sci 2009;86:948–54. 36. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care 2003;41:1284–92. 37. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding in- struments for depression. Two questions are as good as many. J Gen Intern Med 1997;12:439–45. 38. Lim HY, O’Connor PM, Keeffe JE. Low vision services provided by optometrists in Victoria, Australia. Clin Exp Optom 2008;91: 177–82. Gwyn Rees Department of Ophthalmology Health Services Research Unit Centre for Eye Research Australia University of Melbourne Locked Bag 8, East Melbourne Victoria 8002, Australia e-mail: 1336 Depression in Patients with Low Vision—Rees et al. Optometry and Vision Science, Vol. 86, No. 12, December 2009