By Bruce R. Rosenthal, OD, FAAO
Mrs. R.M., an 86-year-old woman with macular degeneration, is brought to a low vision examination by her daughter. She is withdrawn, and has difficulty describing her recent eye care history. Her daughter reports that her mother has stopped going out with friends, and often seems fatigued. During the examination, Mrs. M. finds it hard to concentrate on the low vision devices being shown to her, and is unresponsive to any strategies suggested.
Depression and Vision Loss
Loss of visual function may be caused by eye conditions that affect the ability to read, see faces, or travel independently. This loss can be devastating because of its consequences. Some individuals may be in jeopardy of losing a job, while others may be forced to give up driving, which symbolizes independence and freedom of movement. Still others may be faced with the prospect of being unable to cope independently, and may have to move into a nursing home. It is not unusual for providers of low vision care to witness depression among their patients. According to the Mayo Clinic, many factors have been linked with depression, including: life changes, illness, medications, biochemical factors, history of mental or emotional disorders, and substance abuse. A heart attack, Parkinson's disease, stroke, or vision loss may lead to life changes that can cause depression. Individuals may exhibit the same emotional reactions to the loss of vision as those who lose a loved one or a limb. These reactions include: shock, depression, anxiety, disbelief, grief, denial or anger.
The person may also be affected by the recency of onset, severity, and suddenness of the loss of vision. They may experience a stage of shock where they refuse to think about the present situation, or they may appear unresponsive. This stage is often followed by depression. As the Mehrs state, an individual may then have feelings of hopelessness, lack of self-confidence, suicidal thoughts, self-recrimination, and psycho-motor retardation. As the person with low vision goes from doctor to doctor for the "magic" cure that will restore lost vision, only to be told that nothing further can be done, depression may intensity. "Many doctors, while dealing competently with diagnosis and treatment in the acute phase, are not aware of the patient's reaction to diminished sight", says Dr. Eleanor Faye, Clinical Advisor, Center Education, Lighthouse International.
Patients with vision loss may exhibit a response in any of the four basic psychological domains: emotional, cognitive, perceptual, and behavioral. Clinicians dealing with patients who have impaired vision should look for symptoms of depression that warrant treatment, including:
- A persistent, pervasive depressed mood
- Loss of interest or pleasure in usual activities
- Increase or decrease in appetite or weight
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or excessive/inappropriate guilt
- Impaired thinking or concentration
- Recurrent thoughts of death: suicidal ideas, plans, and attempts
Clinicians working with patients exhibiting these symptoms should help to arrange an appointment with a psychiatrist or psychologist who understands the problems of vision impairment. Having a social worker on the multidisciplinary low vision team can enhance the capability to assess, counsel, or refer the person with depression and vision loss.
Vision Rehabilitation Can Help
Low vision care and other vision rehabilitation interventions can be important steps in the rehabilitation process. Mehr noted that depression could be overcome if tasks could be accomplished that the individual had seen as too difficult to do. Ellerbrock even suggested that mastering tasks, such as navigating to the bathroom alone or reading a letter with an optical device would help to overcome depression. Low vision devices, therefore, become an integral part of the process of regaining self-esteem, overcoming feelings of hopelessness, and regaining emotional strength as compensatory strategies are learned. An additional benefit of the low vision evaluation process, according to Dr. Faye, is the opportunity it affords "the understandably depressed person ... to ask questions about treatment, about the eye disease, and to express the frustration inherent in the experience of losing sight. Usually the realization that they can air their problems and that it's okay to talk about them gets the therapeutic ball rolling."