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 Stepped-care delivery is aimed at long-term disease management that
maximizes the effectiveness and efficiency of resources, the authors
write in the BMJ. Patients start with lower intensity treatments and
only progress to higher intensity interventions if they don't
respond to the first efforts.
“This way long-term disease management needs can be met – which is
attractive for visually impaired older people who are likely to face
further physical decline over time (eye diseases are often
degenerative) that can lead to an increased risk of depression and
anxiety – and the effectiveness and efficiency of resource
allocation can be maximized,” said lead author Hilde van der Aa of
VU University Medical Center in Amsterdam, The Netherlands.
Visual impairment is associated with physical dysfunction, decreased
mobility, limitations in daily life activities and increased
dependency on others, van der Aa told Reuters Health by email.
“About one in three visually impaired older adults experience
subclinical symptoms of depression and anxiety, which is about twice
as high as the prevalence in normally sighted peers,” she said.
Fifteen percent of visually intact older adults have symptoms of
depression and around 2 percent have major depressive disorder, said
Robin Casten of Thomas Jefferson University and the Jefferson
Hospital for Neuroscience in Philadelphia, who was not part of the
new study.
The researchers studied 265 people age 50 or older in Belgium or the
Netherlands who had impaired vision and also some level of
depression or anxiety, but less than required for a clinical
diagnosis.
Half of the group received usual care while the other half was also
enrolled in a stepped-care program involving occupational
therapists, social workers and psychologists from low-vision
rehabilitation organizations.
The providers began by monitoring patient progress with “watchful
waiting” for three months, then delivering guided self-help programs
based on cognitive behavioral therapy for three months, problem
solving treatment for the next three months, and referral to a
general practitioner if necessary at the end of the program.
Patients only moved from one type of treatment to another if they
still have elevated symptoms of depression or anxiety.
The guided self-help program involved face-to-face meetings and
telephone calls designed to promote awareness of depression and
anxiety, negative thought patterns, self-defeating thoughts as well
as pleasurable activities that can still be carried out with visual
impairment.
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Problem-solving treatment involved seven one-hour face-to-face
meetings with social workers who helped patients establish realistic
goals, generate alternative solutions and select the best solution.
Two years after the study began, and one year after all four
consecutive treatments would have been completed, 62 people in the
comparison group, or 46 percent, developed a depressive or anxiety
disorder, compared to 38 people, or 29 percent, in the stepped-care
group.
About a third of people dropped out of the program before the two
years were up.
After guided self-help, many patients were free of clinically
significant symptoms. Only one in five moved to problem solving
therapy and only one in 20 were referred to the general
practitioner, van der Aa said.
“The first step is to screen for depression as it is notoriously
under-detected and under-treated in this population,” Casten said.
“For the most part, older adults with impaired vision become
depressed because of vision-related disability and disengagement in
enjoyable and meaningful activities.”
The stepped-care program allows for standard choices of screening,
monitoring, treating and referring visually impaired older adults
with depression and anxiety in order to prevent them from developing
major disorders, van der Aa said.
Stepped-care has been recommended by the U.K. National Institute for
Health and Care Excellence (NICE) guidelines as the preferred model
to deal with depression and increase efficiency of resource
allocation, she said.
SOURCE: http://bit.ly/1lcMGHP BMJ, online November 5, 2015.
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