We conducted two longitudinal studies of older adults with impaired vision to: l) document the prevalence and incidence of major depression among older people with impaired vision; 2) examine the relationships between depression and disability.  

Major findings include: 1) almost 40% of visually impaired older people have major depression; 2) about 30% of those with macular degeneration in  the second eye became depressed within 6 months of being diagnosed; and 3) depression is related to disability, and this relationship is stronger than that between depression and vision loss.

Representative research publications:
Rovner BW, Zisselman MH, Shmuely-Dulitzki Y.  "Depression and Disability in Elderly Persons With Impaired Vision:  A Follow-Up Study". Journal American Geriatrics Society,  44:  181-184, 1996.

Abstract

• OBJECTIVE:  To determine the prevalence of depressive symptoms and their relationship to disability in older low vision patients.
• DESIGN: Panel study with 2-year follow-up.
• PARTICIPANTS: Community-residing older people (N=31).
• MEASUREMENTS: Geriatric Depression Scale, Community Disability Scale, and Snellen visual acuity. 
• RESULTS: Twelve of 31 patients (38.7%) had GDS scores > or = 11 at baseline.  Two years later, 10 of these 12 patients remained depressed, and three of the 19 (15.8%) previously nondepressed patients had become depressed.  Depressed patients tended to be more disabled functionally than nondepressed patients at follow-up.  The correlation of disability with depression and with vision were examined for the entire sample and revealed a strong correlation between disability and depression (r = .40; P = .013) compared with that of disability and vision (r = .34; P = .032) at baseline and at follow-up: depression (r = .68; P = .001), vision (r = .45; P = .006).  There was no significant correlation between depression and vision at baseline (r = .06; P - .383), but there was a trend toward correlation at follow-up (r = .28; P = .067).
• CONCLUSION: Depressive symptoms are prevalent and persistent among low vision patients and appear more highly related to disability than is vision.  The frequent occurence of depression and the availability of effective treatment argue for its recognition and treatment as possible ways to reduce disability in older persons with low vision.

Rovner BW, Shmuely-Dulitzki Y.  "Screening for Depression in Low-Vision Elderly". International Journal of Geriatric Psychiatry, 12:  955-959, 1997.

Abstract

• OBJECTIVE: To determine the sensitivity and specificity of the Geriatric Depression Scale (GDS) in older low-vision patients, and to compare GDS scores with the diagnosis of major depression in statistical models examining the interrelationships of vision, depression and disability.
• DESIGN: Cross-sectional survey. 
• PARTICIPANTS: Community-residing older persons attending thelow-vision clinic of Wills Eye Hospital, Philadelphia, PA, USA. 
• MEASUREMENTS: Geriatric Depression Scale, DSM-III-R Checklist for Depression, Community Disability Scale and Snellen Visual Acuity. 
• RESULTS: The sensitivity and specificity of the GDS (GDS = 11) were 63% and 77%, respectively.  A receiver operating characteristic curve showed that the GDS's ability to discriminate patients with and without major depression was no better than chance.  Although the GDS was limited as a screen for major depression, it was useful in statistical models examining the interrelationships of vision, depression and disability.
• CONCLUSION: Depressive symptoms are common among elderly patients with impaired vision attending a low-vision clinic.  Although the GDS is unable to discriminate patients with and without major depression in this population, it is valuable as a continuous measure of depressive symptomatology to examine the interrelationships of vision, depression and disability.

Rovner BW, Ganguli M.  "Disability Associated With Impaired Vision:  The Movies Project". Journal of the American Geriatrics Society, (5):  617-619, 1998.

Abstract:

• OBJECTIVE:  To assess how depression and impaired vision relate to disability in older people. 
• DESIGN:  An epidemiological survey of an age-stratified random community sample.
• SETTING:  The rural mid-Monongahela Valley in South-western Pennsylvania. 
• PARTICIPANTS:  A total of 872 noninstitutionalized persons aged 68 and older, fluent in English, and with at least a grade 6 education.
• MEASUREMENTS:  Demographics, self-reported vision impairment, OARS  Instrumental Activities of Daily Living (IADL), and modified Center for Epidemiologic Studies-Depression Scale to assess depression.
• RESULTS: compared with subjects with intact vision, those with impaired vision were more likely to have five or more depressive symptoms (29.7% vs. 8.5%; OR = 4.6, 95% CI = 2.2, 9.6) and to be more functionally impaired (OR = 9.7, 95% CI = 4.9, 19.2).  The number of depressive symptoms (1-4: OR = 2.4, CI = 1.8, 3.4) and (5+:OR = 5.9, CI = 3.6, 9.8) was associated independently with IADL impairment after controlling for vision, age, and gender.
• CONCLUSIONS:  Impaired vision and depression are both associated strongly with functional impairment in this community population of older adults. Depression, however, increases the odds of functional impairment independent of vision impairment.  Treating depression may reduce excess disability associated with impaired vision.

Ranen NG, Pasternak RE, Rovner BW.  "Cisapride in the Treatment of Visual Hallucinations Caused by Vision Loss:  the Charles Bonnet Syndrome". American Journal of Geriatric Psychiatry,  7(3):  264-6, 1999 Summer.

Abstract:

The authors describe the use of cisapride (Propulsid), a potent 5-HT(3) antagonist, in the treatment of visual hallucinations in two patients with vision loss (the Charles Bonnet syndrome).

Galaria, II, Casten, RJ, Rovner, BW. “Development of a Shorter Version of the Geriatric Depression Scale for Visually Impaired Older Patients”. International Psychogeriatrics, 12 (4) : 435-443, 2000.

Abstract

• OBJECTIVE: To validate a shorter version of the Geriatric Depression Scale (GDS) for older, visually impaired patients.
• DESIGN: Cross-sectional survey.
• PARTICIPANTS: Visually impaired adults over age 65 presenting for services at a low vision clinic (N=70).
• MEASUREMENTS: A structured clinical interview to ascertain major depression, and the 15-item GDS to assess depressive symptoms. Multiple logistic regression with the dependent variable clinical diagnosis of major depression and the independent variables, the 15 GDS items. Four items were significant, and were used to form the GDS-Abbreviated (GDS-A) scale. Sensitivity and specificity analyses were performed on various combinations of these four items to generate an effective cutoff score.
• RESULTS: Endorsing any two or more of the following four items – (a) dissatisfied with life, (b) feeling helpless, (c) reporting problems with memory, and (d) lost activities and interests – yielded the best results with a sensitivity of .71 and a specificity of .88. This GDS-A cutoff score better differentiates depressed from nondepressed individuals than the cutoff score of 5 that is recommended for the GDS-15.
• CONCLUSION: The GDS-A’s short format and strong discriminating ability make it an effective, convenient tool for screening visually impaired, older patients for depression.

Casten RJ, Rovner BW, Edmonds SE. “The Relationships among Personality and Vision-Specific Function among Older People with Impaired Vision”. Journal of Aging and Mental Health. Fall 2001 (In Press).

Abstract

• OBJECTIVE: To explore whether personality is related to vision-specific function after controlling for severity of vision loss, health, and depression.
• DESIGN: Cross-sectional survey.
• PARTICIPANTS: Visually impaired older adults seeking services at a low vision clinic (N=93).
• MEASUREMENTS: Interview immediately following low vision evaluations. All data were self-reported, except visual acuity determined by an optometrist. NEO Five-Factor Inventory to evaluate personality, Center for Epidemiologic Studies-Depression Scale to assess depression. Vision-specific function measured by 15 items assessing ability to carry out vision-related tasks. A hierarchical linear regression was performed with vision-specific function as the dependent variable.
• RESULTS: Bivariate analyses indicate that vision-related function is significantly related to visual acuity, conscientiousness and depressive symptoms. Only visual acuity and conscientiousness are significant in the multivariate analysis.
• CONCLUSION: Findings highlight the contribution of personality to function among older people with impaired vision.

Rovner BW, Casten RJ. “Activity Loss and Depression in Age-related Macular Degeneration”. American Journal of Geriatric Psychiatry, 2001 (In Press).

Abstract

• OBJECTIVE: To evaluate patients with bilateral Age-related Macular Degeneration (AMD) to investigate the interrelationships of disease severity, disability and depression. Focus: loss of valued activities as an emblematic disabling consequence of AMD.
• DESIGN: A cross-sectional survey.
• PARTICIPANTS: Older adult patients with bilateral AMD (N=51).
• MEASUREMENTS: Depression was characterized as a CES-D score, a syndromal state based on the CES-D, and as a level of distress (Index of Affective Suffering; IAS).
• RESULTS: Thirty subjects (58.8%) with loss of a valued, discretionary activity had worse visual acuity, more depressive symptoms, and were represented in higher IAS levels than other subjects. Visual acuity was significantly correlated with IAS levels (R=.37; p <= .01) but not with CES-D scores (r=.26; p .05 nor syndromal depression (r=.22; p < .05). A regression model showed that acitvity loss mediated the relationship between visual acuity and IAS level.
• CONCLUSION: Affective distress occurs in AMD, largely to the extent that valued activities are relinquished due to vision loss. IAS levels best illuminated this relationship, suggesting the value of this dimension of affective functioning in studies of the consequences of chronic disease.

Rovner BW, Casten RJ. “Neuroticism Predicts Depression and Disability in Age-related Macular Degeneration”. JAGS, 2001 (In Press).

Abstract

• OBJECTIVE: To investigate the incidence rate of depression, its risk factors and consequences, that is associated with age-related macular degeneration (AMD).
• DESIGN: A prospective cohort study in which subjects were interviewed 6 weeks after the onset of bilateral vision loss and 6 months later.
• PARTICIPANTS: Older adults with new onset bilateral AMD from a retinovascular clinic of a specialty eye hospital (N=51).
• MEASUREMENTS: Depressive symptoms, personality traits, visual acuity, and vision and physical functioning were assessed.
• RESULTS: The baseline prevalence rate of syndromal depression was 23.5% and high levels of depressive symptoms persisted over time. The 6-month incidence rate of depression was 27.8%. The strongest risk factors of incident depression were self-rated and informant-rated neuroticism. Patients who developed syndromal depression were 8.3 times (95% CI, l.l-63.4) more likely than non-depressed patients to become disabled in vision function, independent of change in visual acuity.
• CONCLUSION: AMD is associated with high rates of depression and visual disability independent of severity of vision loss. The personality trait of neuroticism is highly predictive of incident depression and identifies patients at high risk for excess disability. Psychotherapeutic treatments targeted to this group may prevent depression and reduce disability.

Rovner, BW, Casten, RJ. (in press). “Activities Loss and Depression In Age-Related Macular Degeneration.” American Journal of Geriatric Psychiatry.

Abstract

Age-related Macular Degeneration (AMD) is the most frequent cause of severe vision loss in older persons and is associated with high rates of disability and depression. We evaluated 51 patients with bilateral AMD to investigate the interrelationships of disease severity, disability and depression and focused on loss of valued activities as an emblematic disabling consequence of AMD. We characterized depression as a CES-D score, a syndromal state based on the CES-D, and as a level of distress (Index of Affective Suffering; IAS). Thirty subjects (58.8%) had loss of a valued, discretionary activity. They had worse visual acuity, more depressive symptoms, and were represented in higher IAS levels than other subjects. Visual acuity was significantly correlated with IAS levels (r=.37; p<.01) but not with CES-D scores (r=.26; p>.05 nor syndromal depression (r=.22; p>.05). A regression model demonstrated that activity loss mediated the relationship between visual acuity and IAS level. Affective distress occurs in AMD, largely to the extent that valued activities are relinquished due to vision loss. IAS levels best illuminated this relationship, suggesting the value of this dimension of affective functioning in studies of the consequences of chronic disease.

Rovner, BW, Casten, RJ. (in press). “Neuroticism Predicts Depression and Disability in Age-related Macular Degeneration.” American Journal of Geriatric Psychiatry.

Abstract

• Objective: Age-related macular degeneration (AMD) is a common, disabling disorder of older age that is associated with depression. We investigated the incidence rate of depression and its risk factors and consequences in this 6-month longitudinal study.
• Design: A prospective cohort study in which subjects were interviewed 6 weeks after the onset of bilateral vision loss and 6 months later.
• Setting: The sample was recruited from the retinovascular clinic of a specialty eye hospital.
• Participants: Subjects were 51 patients with new onset bilateral AMD.
• Measurements: We assessed depressive symptoms, personality traits, visual acuity, and vision and physical functioning. Additionally, we interviewed informants to obtain independent assessments of subjects’ personality traits.
• Results: The baseline prevalence rate of syndromal depression was 23.5% and high levels of depressive symptoms persisted over time. The 6-month incidence rate of depression was 27.8%. The strongest risk factors for incident depression were self-rated and informant-rated neuroticism. Patients who developed syndromal depression were 8.3 times (95% CI, 1.1-63.4) more likely than non-depressed patients to become disabled in vision function, independent of change in visual acuity.
• Conclusion: AMD is associated with high rates of depression and visual disability independent of severity of vision loss. The personality trait of neuroticism is highly predictive of incident depression and identifies patients at high risk for excess disability. Psychotherapeutic treatments targeted to this group may prevent depression and reduce disability.

Casten, RJ, Rovner, BW, Edmonds, SE. (in press). “The Relationships among Personality and Vision-Specific Function among Older People with Impaired Vision.” Journal of Mental Health and Aging.

Abstract

The current study explored whether personality is related to vision-specific function after controlling for severity of vision loss, health, and depression. The sample comprised 93 visually impaired older people seeking services at a low vision clinic. Subjects were interviewed immediately following their low vision evaluations. All data were self-reported, except visual acuity which was determined by an optometrist. Personality was evaluated with the NEO Five-Factor Inventory, and vision-specific function was measured by 15 items assessing ability to carry out vision-related tasks. Vision-related function was significantly related to acuity, conscientiousness, and depressive symptoms. A hierarchical linear regression was performed in which vision-specific function was the dependent variable. Visual acuity, health, and depression were entered first, and the five personality traits were entered next. Only visual acuity and conscientiousness were significant, explaining 34% of the variance. Findings highlight the contribution of personality to function among older people with impaired vision.