Depression risk can increase for patients living with worsening vision impairment, according to a growing body of literature. Optometry has a number of tools at its disposal to improve quality of life in patients with low vision, including hand-held magnifiers, video magnifiers, telescopes, and audio books.1 But does the optometrist’s duty end once they have dispensed low vision aids and provided the patient with a brief tutorial? While optometrists may not be trained to diagnose or treat mental disorders, they can refer patients for psychological evaluation based on their presentation during an exam. A 2021 study shows that depression risk is almost 3 times greater in patients with low vision compared with individuals without vision impairment (odds ratio [OR], 2.82; 95% CI, 1.90–4.21).2 An enhanced awareness of mental disorders among individuals with vision loss may enable clinicians to encourage these patients to seek appropriate care, akin to how optometry monitors and refers for other systemic diseases, such as diabetes, heart disease, and rheumatoid arthritis.3
Depression, anxiety, and other mental disorders are not unique to individuals with low vision, but vision loss can exacerbate feelings of inadequacy and helplessness, lead to embarrassment, and prompt individuals to discontinue activities that once provided meaning in their lives.4 To ensure adequate mental health treatment for patients with vision loss, optometrists must become familiar with the available resources.
Look for Signs and Evaluate
“I do believe educating eye care professionals on what vision resources are available to their patients in their state and local communities is the first step,” Margo Siegel, a licensed master social worker (LMSW) specializing in treating children, adults and families affected by vision loss explained. “[Optometrists] need to be aware of what symptoms to look for after stating the [low vision] diagnosis and who to refer their patients to if mental health issues are noticed.”
One resource that may provide a starting point for determining depression-related symptoms is the Patient Health Questionnaire (PHQ)-9, a 9-question diagnostic tool used to detect depression severity. Although the PHQ-9 is not specific to determining depression presence and severity among individuals with vision impairment, research suggests that this diagnostic tool demonstrates appropriateness and possesses the psychometric properties necessary for screening these individuals.5 No formal training in mental health counseling or Rasch procedures is necessary to obtain clinically meaningful data that can be shared with psychologists, psychiatrists, social workers, and other mental health professionals.6
“[The PHQ-9] is a simple test that can give you some solid clinical data when you go to refer your patients [for mental health care]” according to Tracy Matchinski, OD, an associate professor at the Illinois College of Optometry who practices low vision rehabilitation at both the Chicago Lighthouse for the Blind and the Illinois College of Optometry. “It will give you insight into the patient’s mental health status, because not all depression is easily visible to those not trained in mental health.”
Clinically validated diagnostic instruments can help clinicians identify depression, but sometimes a simple conversation with the patient and correspondence with the primary care physician (PCP) can also be useful. “Loss of vision represents a big change in one’s life and a big change in one’s health status, and we should be asking our low vision patients how they are coping with their vision impairment,” according to Rebecca Marinoff, OD, an associate clinical professor at the State University of New York (SUNY) College of Optometry who serves as the institution’s low vision rehabilitation residency supervisor. “If we find evidence of a mental health concern, we should let the patient know of our concerns and write a letter (with the patient’s consent) to the patient’s PCP and ask the PCP to consider a referral to a mental health provider. The PCP is in a good position to make this referral because they are able to refer the patient to a mental health provider who is on the patient’s insurance panel.”
Know When to Suspect Depression
While any individual affected by vision loss may exhibit symptoms of depression, certain pathologies and demographic factors may increase this risk. Research shows that up to 8.6% of adults aged 60 and older with vision loss meet the diagnostic criteria for a depressive disorder — a figure significantly higher than in individuals of similar age without visual impairment — and 10.9% to 43% report depressive symptoms that are clinically significant.7,8 It also shows that approximately 30% of patients with age-related macular degeneration (AMD) develop a depressive disorder after receiving an AMD diagnosis in their second eye.7 Other factors influencing depression risk among individuals with vision loss include nonWhite ethnicity, the presence of multiple eye pathologies, poor self-reported health, and visual acuity severity level.9,10 Suicidal ideation, an indicator of severe depression, has even been linked with visual impairment in older adults.7 Patients in this age group were particularly affected by the COVID-19 pandemic, resulting in a high prevalence in suicidal ideation (32.5%).11 While lockdowns, social restrictions, and isolation procedures may no longer be as commonplace as they were just a few years ago, pandemic-associated depression appears to persist, and this depression, paired with vision impairment, may prove catastrophic for patients with low vision. Vision impairment type may also affect depression severity among these individuals, with diabetic retinopathy making these patients more prone to suicidal ideation risk (adjusted odds ratio [AOR], 2.4; 95% CI, 1.0-5.8; P =.038).11 Existing depression may increase this risk even further.11
Depression severity should determine how active a role the clinician takes in referring patients for care. “If a patient shows more clinical signs and the PHQ score is worse, we take an active role in referring them. It might be support group referral, which we do for all the patients, or if there are more signs, we’ll take a more aggressive role to talk about going to the psychologist or social worker,” Dr Matchinski said.
Partner With A Mental Health Expert
Clinicians may expect to face challenges when addressing mental health needs among their patients. Self-stigmatization may prevent these individuals from discussing these concerns in the optometrist’s chair, and some clinicians may believe that these individuals do not want to discuss them.12 A clinician’s approach toward steering their patients toward mental health treatment may not always involve patient-doctor conversations. More subtle methods may involve posting information on websites or displaying posters in low vision clinics.12 While optometrists may be aware of these mental health concerns among their patients and take different approaches toward addressing them, there do not appear to be any uniform protocols to guide clinicians or determine how active a role they must play in helping their patients secure services that may improve their quality of life.
Ms Siegel questions whether these dedicated eye care professionals have taken an aggressive-enough approach to ensure their patients’ mental health needs are addressed. “Many of my clients over the years have shared they were given a negative vision diagnosis during their appointment either in the hospital or medical office and then released without any further information about resources available to them on how to best cope with their current and/or future vision loss,” she said. “I do not believe the majority of eye care specialists are referring patients on a consistent basis when they notice possible mental health symptoms.”
Referring patients for mental health counseling may not only improve depressive symptoms, it may also lead to better vision-related outcomes. “With the right mental health support treatment, we have better outcomes,” Dr Matchinski said. “We have patients who are better able to adhere to the management of their eye condition and patients who are better able to participate in their own vision rehabilitation.”
Demonstrate Tools to Help Patients Thrive
But optometrists do not need to wait for their patients to overcome their mental health struggles or go through a referral process before enacting strategies to improve quality of life. In fact, an investigation shows that low vision behavior activation therapy, which includes demonstrations on how to use low vision devices, modifications for environmental lighting, and setting reasonable and attainable goals, outperformed therapy alone and reduced depression risk by 50%.13
Optometrists may not specialize in treating mental disorders, but providing patients with options that allow for greater independence can help to alleviate or reduce depression. Working in tandem with a mental health professional can help individuals with vision loss experience even greater quality of life improvements.
- Turbert D, Gudgel D. Low vision assistive devices. American Academy of Ophthalmology. Updated September 23, 2021. Accessed February 15, 2023. https://www.aao.org/eye-health/diseases/low-vision-assistive-devices
- Mayro EL, Murchison AP, Hark LA, et al. Prevalence of depressive symptoms and associated factors in an urban, ophthalmic population. Eur J Ophthalmol. 2021;31(2):740-747. doi:10.1177/1120672120901701
- Mukamal R. 20 surprising health problems an eye exam can catch. American Academy of Ophthalmology. Updated April 29, 2022. Accessed February 15, 2023. https://www.aao.org/eye-health/tips-prevention/surprising-health-conditions-eye-exam-detects
- Casten R, Rovner B. Depression in age-related macular degeneration. J Vis Impair Blind. 2008;102(10):591-599.
- Lamoureux EL, Tee HW, Pesudovs K, Pallant JF, Keeffe JE, Rees G. Can clinicians use the PHQ-9 to assess depression in people with vision loss? Optom Vis Sci. 2009;86(2):139-145. doi:10.1097/OPX.0b013e318194eb47
- Gothwal VK, Bagga DK, Sumalini R. Rasch validation of the PHQ-9 in people with visual impairment in South India. J Affect Disord. 2014;167:171-7. doi:10.1016/j.jad.2014.06.019
- Demmin DL, Silverstein SM. Visual impairment and mental health: unmet needs and treatment options. Clin Ophthalmol. 2020;14:4229-4251. doi:10.2147/OPTH.S258783
- van der Aa HPA, Comijs HC, Penninx BWJH, van Rens GHMB, van Nispen RMA. Major depressive and anxiety disorders in visually impaired older adults. Invest Ophthalmol Vis Sci. 2015;56(2):849-854. doi:10.1167/iovs.14-15848
- Nollett C, Ryan B, Bray N, et al. Depressive symptoms in people with vision impairment: a cross-sectional study to identify who is most at risk. BMJ Open. 2019;9(1):e026163. doi:10.1136/bmjopen-2018-026163
- Augustin A, Sahel J-A, Bandello F, et al. Anxiety and depression prevalence rates in age-related macular degeneration. Invest Ophthalmol Vis Sci. 2007;48(4):1498-503. doi:10.1167/iovs.06-0761
- Tantirattanakulchai P, Hounnaklang N, Pongsachareonnont PF, Khambhiphant B, Win N, Tepjan S. Prevalence and factors associated with suicidal ideation among older people with visual impairments attending an eye center during the COVID-19 pandemic: a hospital-based cross-sectional study. Clin Ophthalmol. Published online March 19,2023. doi:10.2147/OPTH.S403003
- van Munster EPJ, van der Aa HPA, Verstraten P, van Nispen RMA. Barriers and facilitators to recognize and discuss depression and anxiety experienced by adults with vision impairment or blindness: a qualitative study. BMC Health Serv Res. 2021;21(1):749. doi:10.1186/s12913-021-06682-z
- Rovner BW, Casten RJ, Hegel MT, et al. Low vision depression prevention trial in age-related macular degeneration. Ophthalmol. 2014;121(11):2204-2212. doi:10.1016/j.ophtha.2014.05.002