Age-related Macular Degeneration, Depression
Conditions
Keywords
age-related macular degeneration, depression, vision loss
Brief summary
This randomized, controlled clinical trial, the Low Vision Depression Prevention TriAL (VITAL), will test the efficacy of collaborative low vision rehabilitation (LVR) to prevent depressive disorders in Age-Related Macular Degeneration (AMD). In this innovative intervention, a low vision occupational therapist collaborates with a low vision optometrist to develop and implement a care plan based on a subject's vision status, rehabilitation potential, and personal rehabilitation goals. An independent rater masked to treatment assignment will assess depressive disorders meeting DSM-IV criteria (primary outcome) and targeted vision function and vision-related quality of life (secondary outcomes) at baseline and then at 4 months to evaluate short-term effects (main trial end point) and at 12 months to evaluate long-term effects.
Detailed description
Age-related macular degeneration (AMD) is the leading cause of blindness in older persons in the U.S. and affects more than 10 million people. One third of patients with AMD become clinically depressed when they lose the ability to pursue valued activities. Because their depression is disabling and unlikely to be treated, preventing depression in AMD is a public health imperative as the population ages. We will recruit 200 subjects who have bilateral AMD and subthreshold depressive symptoms. Their bilateral vision loss and subthreshold depressive symptoms increase their risk to develop more severe depressive disorders and functional decline. We will randomize eligible subjects to collaborative Low Vision Rehabilitation (LVR) (optometrist and home-based OT) or enhanced LVR (optometrist and home-based Supportive Therapy). In this study, usual care LVR is enhanced with Supportive Therapy (ST), which is a standardized placebo psychological treatment that controls for attention. Many older persons with AMD understandably become depressed when their vision loss prevents them from pursuing valued goals. This necessitates a disease management strategy that combines treatment for vision loss and depression. Because depression in AMD is rarely treated, preventing depression is more sensible than waiting to treat it after diagnosis or failing to treat it at all. As the population ages and more people are affected with AMD, finding ways to prevent depression and improve daily functioning has great public health importance. For these reasons, the VITAL Trial has high clinical significance to patients with AMD, and wider public health significance as our society confronts the challenge of caring for the growing population of older adults with chronic disabilities.
Interventions
BEHAVIORALBA-LVR
Low vision clinic-based optometry plus 6 in-home occupational therapy visits
BEHAVIORALST-LVR
Clinic-based low vision optometry plus 6 in-home sessions of Supportive Therapy
Sponsors
Dartmouth-Hitchcock Medical Center
Johns Hopkins University
Thomas Jefferson University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Age at least 65 years old * Bilateral AMD * Subthreshold depressive symptoms * At least 1 vision goal that is important yet difficult to carry out
Exclusion criteria
* Uncontrolled glaucoma, diabetic retinopathy, corneal dystrophy, or cataracts for which surgery within 6 months is likely will be exclusionary conditions * Current diagnosis of depression * Cognitive impairment * Life-threatening illness or any other health conditions that interferes with study activities. * Patients who have received low vision rehabilitation or home-based OT in the preceding 12 months will be excluded.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Depression | 4 months | The primary outcome was a DSM-IV diagnosis of major or minor depression based on the Patient Health Questionnaire-9 (PHQ-9).13 The PHQ-9 includes the 9 criteria that define DSM-IV diagnoses of depression and is valid in low-vision patients. A scoring algorithm determines whether the profile of symptoms meets categorical diagnoses of depression. The model is adjusted for treatment group, vision stratum (20/70 to 20/100 vs. \< 20/100), baseline better eye scotoma size, baseline depression scores \[Patient Health Questionnaire (PHQ-9)\], Medical Outcome Study score (MOS-6), which is a global index of self-rated physical and mental health, and baseline neuroticism scores. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Quality of Life: Dependency | 4 months | Self-reported depencency was assessed using the Dependency subscale from the National Eye Institute Vision Function Questionaire-25 (NEI-VFQ). Scores range from 0 to 100, with higher scores indicating less dependency. Changes in least square means from baseline to 4 months are presented. |
| Vision Function: Near Activities | 4 months | Near vision function was assessed using the near activities subscale of the National Eye Institute Vision Function Questionaire-25 (NEI-VFQ). This subscale measures self-reported difficulty in completing activities that require near function. The subscale is scored from 0 to 100 with higher scores indicating better function. Changes in least squares mean (95% CI) from month 0 to month 4 are reported. |
| Vision Function: Distance Activities | 4 months | Distance vision function was assessed using the near activities subscale of the National Eye Institute Vision Function Questionaire-25 (NEI-VFQ). This subscale measures self-reported difficulty in completing activities that require distance function. The subscale is scored from 0 to 100 with higher scores indicating better function. Changes in least squares mean (95% CI) from month 0 to month 4 are reported. |
| Quality of Life: Role Functioning | 4 months | Self-reported role functioning was assessed using the Role Difficulties subscale from the National Eye Institute Vision Function Questionaire-25 (NEI-VFQ). Scores range from 0 to 100, with higher scores indicating fewer role difficulties . Changes in least square means from baseline to 4 months are presented. |
| Quality of Life: Social Function | 4 months | Self-reported social function was assessed using the Social Functioning subscale from the National Eye Institute Vision Function Questionaire-25 (NEI-VFQ). Scores range from 0 to 100, with higher scores indicating better social function. Changes in least square means from baseline to 4 months are presented. |
| Quality of Life: Mental Health | 4 months | Self-reported menthal health was assessed using the Mental Health subscale from the National Eye Institute Vision Function Questionaire-25 (NEI-VFQ). Scores range from 0 to 100, with higher scores indicating better mental health. Changes in least square means from baseline to 4 months are presented. |
Countries
United States
Participant flow
Recruitment details
Subjects were recruited from July 2009 through Feb 2013 from a large, private retina practice.
Participants by arm
| Arm | Count |
|---|---|
| BA-LVR In BA-LVR, a low vision occupational therapist (OT) will deliver Behavior Activation (BA), a psychological treatment to prevent depression. This will be administered in the context of the standard of low vision care for OTs as defined by the American Occupational Therapy Association (AOTA). The OTs will collaborate with low vision optometrists, who will deliver the standard of low vision care as defined by the American Optometric Association. The optometrists will evaluate remaining vision and magnification needs, prescribe optical devices, and provide the OTs with initial care plans. The OTs will subsequently meet with subjects in their homes 6 times over 12 weeks to enhance device use, home modifications, and compensatory strategies.
BA-LVR: Low vision clinic-based optometry plus 6 in-home occupational therapy visits | 96 |
| ST-LVR Subjects randomized to ST-LVR will receive clinic-based low vision optometry, in addition to 6 in-home Supportive Therapy (ST) sessions. ST is a placebo condition that controls for the attention that subjects in the active treatment arm will receive.
ST-LVR: Clinic-based low vision optometry plus 6 in-home sessions of Supportive Therapy | 92 |
| Total | 188 |
Baseline characteristics
| Characteristic | BA-LVR | ST-LVR | Total |
|---|---|---|---|
| Age, Continuous | 85.2 years STANDARD_DEVIATION 6.6 | 82.7 years STANDARD_DEVIATION 6.9 | 84.0 years STANDARD_DEVIATION 6.8 |
| Ethnicity (NIH/OMB) Hispanic or Latino | 1 Participants | 0 Participants | 1 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 95 Participants | 92 Participants | 187 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 1 Participants | 0 Participants | 1 Participants |
| Race (NIH/OMB) Black or African American | 1 Participants | 2 Participants | 3 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 94 Participants | 90 Participants | 184 Participants |
| Sex: Female, Male Female | 70 Participants | 62 Participants | 132 Participants |
| Sex: Female, Male Male | 26 Participants | 30 Participants | 56 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 11 / 96 | 5 / 92 |
| serious Total, serious adverse events | 30 / 96 | 28 / 92 |
Outcome results
Primary
Depression
The primary outcome was a DSM-IV diagnosis of major or minor depression based on the Patient Health Questionnaire-9 (PHQ-9).13 The PHQ-9 includes the 9 criteria that define DSM-IV diagnoses of depression and is valid in low-vision patients. A scoring algorithm determines whether the profile of symptoms meets categorical diagnoses of depression. The model is adjusted for treatment group, vision stratum (20/70 to 20/100 vs. \< 20/100), baseline better eye scotoma size, baseline depression scores \[Patient Health Questionnaire (PHQ-9)\], Medical Outcome Study score (MOS-6), which is a global index of self-rated physical and mental health, and baseline neuroticism scores.
Time frame: 4 months
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| BA-LVR | Depression | Total Sample | 11 participants |
| BA-LVR | Depression | Worse Vision Group (< 20/100) | 5 participants |
| BA-LVR | Depression | Better Vision Group (20/70 to 20/100) | 6 participants |
| ST-LVR | Depression | Total Sample | 18 participants |
| ST-LVR | Depression | Worse Vision Group (< 20/100) | 11 participants |
| ST-LVR | Depression | Better Vision Group (20/70 to 20/100) | 7 participants |
p-value: 0.06795% CI: [0.27, 1.06]Mantel Haenszel
Secondary
Quality of Life: Dependency
Self-reported depencency was assessed using the Dependency subscale from the National Eye Institute Vision Function Questionaire-25 (NEI-VFQ). Scores range from 0 to 100, with higher scores indicating less dependency. Changes in least square means from baseline to 4 months are presented.
Time frame: 4 months
| Arm | Measure | Value (LEAST_SQUARES_MEAN) |
|---|---|---|
| BA-LVR | Quality of Life: Dependency | 2.07 units on a scale |
| ST-LVR | Quality of Life: Dependency | 5.54 units on a scale |
p-value: 0.6895% CI: [-12.22, 5.29]Mixed Models Analysis
Secondary
Quality of Life: Mental Health
Self-reported menthal health was assessed using the Mental Health subscale from the National Eye Institute Vision Function Questionaire-25 (NEI-VFQ). Scores range from 0 to 100, with higher scores indicating better mental health. Changes in least square means from baseline to 4 months are presented.
Time frame: 4 months
| Arm | Measure | Value (LEAST_SQUARES_MEAN) |
|---|---|---|
| BA-LVR | Quality of Life: Mental Health | 2.23 units on a scale |
| ST-LVR | Quality of Life: Mental Health | 4.25 units on a scale |
p-value: 0.6895% CI: [-9.8, 5.76]Least squares mean
Secondary
Quality of Life: Role Functioning
Self-reported role functioning was assessed using the Role Difficulties subscale from the National Eye Institute Vision Function Questionaire-25 (NEI-VFQ). Scores range from 0 to 100, with higher scores indicating fewer role difficulties . Changes in least square means from baseline to 4 months are presented.
Time frame: 4 months
| Arm | Measure | Value (LEAST_SQUARES_MEAN) |
|---|---|---|
| BA-LVR | Quality of Life: Role Functioning | 2.33 units on a scale |
| ST-LVR | Quality of Life: Role Functioning | .93 units on a scale |
p-value: 0.6895% CI: [-4.04, 6.82]Least squares mean
Secondary
Quality of Life: Social Function
Self-reported social function was assessed using the Social Functioning subscale from the National Eye Institute Vision Function Questionaire-25 (NEI-VFQ). Scores range from 0 to 100, with higher scores indicating better social function. Changes in least square means from baseline to 4 months are presented.
Time frame: 4 months
| Arm | Measure | Value (LEAST_SQUARES_MEAN) |
|---|---|---|
| BA-LVR | Quality of Life: Social Function | -.38 units on a scale |
| ST-LVR | Quality of Life: Social Function | -2.00 units on a scale |
p-value: 0.6895% CI: [-5.94, 9.17]Least squares mean
Secondary
Vision Function: Distance Activities
Distance vision function was assessed using the near activities subscale of the National Eye Institute Vision Function Questionaire-25 (NEI-VFQ). This subscale measures self-reported difficulty in completing activities that require distance function. The subscale is scored from 0 to 100 with higher scores indicating better function. Changes in least squares mean (95% CI) from month 0 to month 4 are reported.
Time frame: 4 months
| Arm | Measure | Value (LEAST_SQUARES_MEAN) |
|---|---|---|
| BA-LVR | Vision Function: Distance Activities | 0.31 units on a scale |
| ST-LVR | Vision Function: Distance Activities | 1.12 units on a scale |
p-value: 0.7595% CI: [-5.92, 4.3]Linear Mixed effects model
Secondary
Vision Function: Near Activities
Near vision function was assessed using the near activities subscale of the National Eye Institute Vision Function Questionaire-25 (NEI-VFQ). This subscale measures self-reported difficulty in completing activities that require near function. The subscale is scored from 0 to 100 with higher scores indicating better function. Changes in least squares mean (95% CI) from month 0 to month 4 are reported.
Time frame: 4 months
| Arm | Measure | Value (LEAST_SQUARES_MEAN) |
|---|---|---|
| BA-LVR | Vision Function: Near Activities | 4.78 units on a scale |
| ST-LVR | Vision Function: Near Activities | 2.36 units on a scale |
p-value: 0.3495% CI: [-2.58, 7.41]Least squares mean