title: Stepped care for depression and anxiety in visually impaired older adults: multicentre randomised controlled trial.
abstract: OBJECTIVE
  Is stepped care compared with usual care effective in preventing the onset of major depressive, dysthymic, and anxiety disorders in older people with visual impairment (caused mainly by age related eye disease) and subthreshold depression and/or anxiety?
  
  
  METHODS
  265 people aged ≥50 were randomly assigned to a stepped care programme plus usual care (n=131) or usual care only (n=134). Supervised occupational therapists, social workers, and psychologists from low vision rehabilitation organisations delivered the stepped care programme, which comprised watchful waiting, guided self help based on cognitive behavioural therapy, problem solving treatment, and referral to a general practitioner. The primary outcome was the 24 month cumulative incidence (seven measurements) of major depressive dysthymic and/or anxiety disorders (panic disorder, agoraphobia, social phobia, and generalised anxiety disorder). Secondary outcomes were change in symptoms of depression and anxiety, vision related quality of life, health related quality of life, and adaptation to vision loss over time up to 24 months' follow-up.
  
  
  CONCLUSIONS
  62 participants (46%) in the usual care group and 38 participants (29%) from the stepped care group developed a disorder. The intervention was associated with a significantly reduced incidence (relative risk 0.63, 95% confidence interval 0.45 to 0.87; P=0.01), even if time to the event was taken into account (adjusted hazard ratio 0.57, 0.35 to 0.93; P=0.02). The number needed to treat was 5.8 (3.5 to 17.3). The dropout rate was fairly high (34.3%), but rates were not significantly different for the two groups, indicating that the intervention was as acceptable as usual care. Participants who volunteered and were selected for this study might not be representative of visually impaired older adults in general (responders were significantly younger than non-responders), thereby reducing the generalisability of the outcomes.
  
  
  CONCLUSIONS
  Stepped care seems to be a promising way to deal with depression and anxiety in visually impaired older adults. This approach could lead to standardised strategies for the screening, monitoring, treatment, and referral of visually impaired older adults with depression and anxiety.
  
  
  BACKGROUND
  Funded by ZonMw InZicht, the Dutch Organisation for Health Research and Development-InSight Society. There are no competing interests. Full dataset and statistical code are available from the corresponding author.Study registration www.trialregister.nl NTR3296.
authors.affiliation: Department of Ophthalmology and EMGO+ Institute for Health and Care Research (EMGO+), VU University Medical Centre, 1081 HV, Amsterdam, Netherlands h.vanderaa@vumc.nl.
authors.forename: Hilde P A
authors.initials: HP
authors.lastname: van der Aa
authors.affiliation: Department of Ophthalmology and EMGO+ Institute for Health and Care Research (EMGO+), VU University Medical Centre, 1081 HV, Amsterdam, Netherlands.
authors.forename: Ger H M B
authors.initials: GH
authors.lastname: van Rens
authors.affiliation: Department of Psychiatry VUmc/GGZinGeest, 1081HL Amsterdam, Netherlands.
authors.forename: Hannie C
authors.initials: HC
authors.lastname: Comijs
authors.affiliation: School of Optometry and Vision Sciences, Cardiff University, Cardiff CF24 4HQ, United Kingdom.
authors.forename: Tom H
authors.initials: TH
authors.lastname: Margrain
authors.affiliation: Department of Epidemiology and Biostatistics, VU University Medical Centre, 1081 HV, Amsterdam, Netherlands.
authors.forename: Francisca
authors.initials: F
authors.lastname: Gallindo-Garre
authors.affiliation: Department of Epidemiology and Biostatistics, VU University Medical Centre, 1081 HV, Amsterdam, Netherlands.
authors.forename: Jos W R
authors.initials: JW
authors.lastname: Twisk
authors.affiliation: Department of Ophthalmology and EMGO+ Institute for Health and Care Research (EMGO+), VU University Medical Centre, 1081 HV, Amsterdam, Netherlands.
authors.forename: Ruth M A
authors.initials: RM
authors.lastname: van Nispen
mesh_terms: D000368:Aged; D001007:Anxiety / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D003863:Depression / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D039721:Diagnostic and Statistical Manual of Mental Disorders; D005260:Female; D006801:Humans; D008134:Long-Term Care / Q000379:methods; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011340:Problem Solving; D011569:Psychiatric Status Rating Scales; D011615:Psychotherapy, Group / Q000379:methods; D011788:Quality of Life; D014786:Vision Disorders / Q000150:complications / Q000523:psychology; D019987:Persons with Visual Disabilities / Q000523:psychology*