Problem-Solving Treatment Helps Prevent Depression in Patients With Age-Related Macular Degeneration

August 8, 2007 — Problem-solving treatment (PST) may help prevent depression in patients with age-related macular degeneration (AMD), according to the results of a randomized controlled trial reported in the August issue of the Archives of General Psychiatry. This treatment prevented depressive disorders and loss of valued activities in the short term, but these benefits were not maintained over time, suggesting that booster treatments may be needed.
"Age-related macular degeneration is a prevalent disease of aging that may cause irreversible vision loss, disability, and depression," write Barry W. Rovner, MD, from Jefferson Medical College in Philadelphia, Pennsylvania, and colleagues. "The latter is rarely recognized or treated in ophthalmologic settings.... [AMD] provides an appealing model for depression prevention research because its severity is readily quantified, it affects men and women equally, and has no biological symptoms that overlap with depression and therefore avoids the problem of confounding behavioral outcomes with underlying disease symptoms."
At outpatient ophthalmology offices in Philadelphia, 206 patients aged 65 years or older were randomized to PST (6 home-based therapy sessions during an 8-week period; n = 105) or to usual care (n = 101). Participants were recently diagnosed with neovascular AMD in 1 eye and with preexisting AMD in the other eye.
The main endpoints were diagnoses of depressive disorders based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV); scores on the National Eye Institute Vision Function Questionnaire-17 (NEI VFQ-17), a subset of the 52-item scale; and rates of giving up valued activities. Short-term outcomes were evaluated at 2 months, and maintenance effects were evaluated at 6 months.
Compared with controls, the intervention group had a lower 2-month incidence rate of depressive disorders (11.6% vs 23.2%; odds ratio [OR], 0.39; 95% confidence interval [CI], 0.17 - 0.92; P = .03) and of giving up a valued activity (22 vs 37; OR, 0.48; 95% CI, 0.25 - 0.96; P = .04). Although most of these benefits had decreased at 6-month follow-up, patients who had received PST were less likely to have persistent depression (P = .04).
"Problem-solving treatment prevented depressive disorders and loss of valued activities in patients with age-related macular degeneration as a short-term treatment, but these benefits were not maintained over time," the authors write. "Booster or rescue treatments may be necessary to sustain problem-solving treatment's preventative effect. This study adds important new information to the emerging field of enhanced-care models to prevent or treat depression in older persons."
Limitations of the study include generalizability limited by the unique visual characteristics of the patient sample, the unclear effects of attrition, and the lack of a control treatment group receiving comparable attention without PST.
The National Institute of Mental Health, the National Eye Institute, and the Farber Institute for Neurosciences of Thomas Jefferson University supported this study. The authors have disclosed no relevant financial relationships.
In an accompanying editorial, Charles F. Reynolds III, MD, from the University of Pittsburgh School of Medicine in Pennsylvania, and colleagues note that teaching effective coping skills during brief, depression-specific, behaviorally oriented psychotherapy may be preferable to prescribing antidepressants.
"However, additional studies are needed to demonstrate durable protective effects," Dr. Reynolds and colleagues write. "Problem-solving therapy for primary care appears to be a good candidate for future testing, perhaps as a component of stepped-care interventions, in which patients first receive lower-cost, lower-intensity efforts, followed by stepped-up (more intensive) care based on need. Given the substantial barriers to good treatment of depression in old age, preventing depression may be a more sensible population-based approach."
The National Institute of Mental Health, the University of Pittsburgh Medical Center, and the John A. Hartford Foundation supported this editorial. The authors have disclosed no financial relationships.
Arch Gen Psychiatry. 2007;64:884-885, 886-892.