title: Low vision depression prevention trial in age-related macular degeneration: a randomized clinical trial.
abstract: OBJECTIVE
  To compare the efficacy of behavior activation (BA) + low vision rehabilitation (LVR) with supportive therapy (ST) + LVR to prevent depressive disorders in patients with age-related macular degeneration (AMD).
  
  
  METHODS
  Single-masked, attention-controlled, randomized, clinical trial with outcome assessment at 4 months.
  
  
  METHODS
  Patients with AMD and subsyndromal depressive symptoms attending retina practices (n = 188).
  
  
  METHODS
  Before randomization, all subjects had 2 outpatient LVR visits, and were then randomized to in-home BA+LVR or ST+LVR. Behavior activation is a structured behavioral treatment that aims to increase adaptive behaviors and achieve valued goals. Supportive therapy is a nondirective, psychological treatment that provides emotional support and controls for attention.
  
  
  METHODS
  The Diagnostic and Statistical Manual IV defined depressive disorder based on the Patient Health Questionnaire-9 (primary outcome), Activities Inventory, National Eye Institute Vision Function Questionnaire-25 plus Supplement (NEI-VFQ), and NEI-VFQ quality of life (secondary outcomes).
  
  
  RESULTS
  At 4 months, 11 BA+LVR subjects (12.6%) and 18 ST+LVR subjects (23.4%) developed a depressive disorder (relative risk [RR], 0.54; 95% CI, 0.27-1.06; P = 0.067). In planned adjusted analyses the RR was 0.51 (95% CI, 0.27-0.98; P = 0.04). A mediational analysis suggested that BA+LVR prevented depression to the extent that it enabled subjects to remain socially engaged. In addition, BA+LVR was associated with greater improvements in functional vision than ST+LVR, although there was no significant between-group difference. There was no significant change or between-group difference in quality of life.
  
  
  CONCLUSIONS
  An integrated mental health and low vision intervention halved the incidence of depressive disorders relative to standard outpatient LVR in patients with AMD. As the population ages, the number of persons with AMD and the adverse effects of comorbid depression will increase. Promoting interactions between ophthalmology, optometry, rehabilitation, psychiatry, and behavioral psychology may prevent depression in this population.
authors.affiliation: Departments of Psychiatry and Neurology, Jefferson Medical College, Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania. Electronic address: barry.rovner@jefferson.edu.
authors.forename: Barry W
authors.initials: BW
authors.lastname: Rovner
authors.affiliation: Department of Psychiatry and Human Behavior, Jefferson Medical College, Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania.
authors.forename: Robin J
authors.initials: RJ
authors.lastname: Casten
authors.affiliation: Departments of Psychiatry and Community & Family Medicine, Dartmouth Medical School, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.
authors.forename: Mark T
authors.initials: MT
authors.lastname: Hegel
authors.affiliation: Lions Vision Research and Rehabilitation Center, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Massof
authors.affiliation: Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Jefferson Medical College, Philadelphia, Pennsylvania.
authors.forename: Benjamin E
authors.initials: BE
authors.lastname: Leiby
authors.affiliation: Department of Ophthalmology, Wills Eye Institute, Jefferson Medical College, Philadelphia, Pennsylvania.
authors.forename: Allen C
authors.initials: AC
authors.lastname: Ho
authors.affiliation: Department of Ophthalmology, Wills Eye Institute, Jefferson Medical College, Philadelphia, Pennsylvania.
authors.forename: William S
authors.initials: WS
authors.lastname: Tasman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001521:Behavior Therapy; D003866:Depressive Disorder / Q000175:diagnosis / Q000517:prevention & control*; D005260:Female; D006305:Health Status Indicators; D006801:Humans; D008268:Macular Degeneration / Q000523:psychology*; D008297:Male; D010555:Personality Inventory; D011788:Quality of Life / Q000523:psychology; D018434:Sickness Impact Profile; D016037:Single-Blind Method; D011795:Surveys and Questionnaires; D015354:Vision, Low / Q000523:psychology* / Q000534:rehabilitation; D014785:Vision, Ocular / Q000502:physiology; D014792:Visual Acuity / Q000502:physiology