It is well established that people with vision impairment have an increased risk of depression compared with those without impaired vision.1–4 Studies conducted largely in the United States have found that up to one-third of all people with vision impairment report clinically significant depressive symptoms.4 Depression has been shown to exacerbate disability and further reduce levels of functioning in this group independent of vision loss.5,6 Several treatment options for depression are available. Evidence-based reviews have highlighted the most effective medicinal and therapeutic approaches,7,8 and clinical guidelines outlining the recommended treatment approach for different levels of depressive symptoms have been published.9 Despite this, depression often remains undetected and therefore untreated in people with vision impairment.5,10 For example, in a study of patients attending a tertiary eye care clinic, we found that only 20% of those reporting clinically significant levels of depressive symptoms were receiving any form of treatment for emotional problems.11
Much emphasis has been placed on detecting depression in general practice. However, difficulties identifying depression in patients with chronic illness have been documented in primary care settings,12,13 and doctor-patient communication concerning emotional health has also been highlighted as problematic for older adults and those with sensory impairments.14,15 Indeed, patients with vision impairment and depression have been identified as a group in which depression is least likely to be recognized by their general practitioners.16
Eye health practitioners, including ophthalmic nurses, ophthalmologists, optometrists, orthoptists, and rehabilitation workers are key care providers for people with vision impairment and could play a vital role in detecting depression.17 It has been suggested that such practitioners could screen for depression and refer patients for psychological services when necessary.17,18 However, a recent survey indicated that identifying depression is not a routine part of patient care for these professionals.19,20 Less than 5% of respondents reported that they use a depression screening tool although they expressed a strong desire to do so. That survey also found that practitioners' confidence, beliefs about depression and its treatment, and perception of barriers were significantly associated with likelihood of identifying and responding to depression.20 Although practitioners reported awareness of the symptoms of depression and held positive beliefs about the efficacy of treatments for depression, a range of barriers were identified and participating practitioners were keen to receive specialist training in depression.19,20
Research in other health care settings has also indicated that practitioners' confidence levels are associated with efforts to identify and respond to depression21 and can be effectively targeted by training programs.22–24 For example, training programs conducted in aged care settings, nursing, and general practice have been shown to increase knowledge and confidence in detecting depression as well as to reduce perceived barriers to responding to depression.25–27 Such training programs have also been shown to change practice in such a way that is likely to increase the detection and referral of patients with suspected depression.28–30
In response, we have developed a training program on depression specifically for eye health professionals based on the training needs identified by them.19,20 The training program aims to improve knowledge about the nature and etiology of depression and the effectiveness of treatment options, to enhance participants' confidence in detecting depression in patients with vision impairment, to facilitate the development of local referral pathways, and to assist participants to overcome perceived barriers to responding to depression. Given that our previous research has indicated that practitioners work in different settings have access to different resources and face different barriers, the training program does not teach a “one size fits all” approach but rather supports the participants to develop systems and procedures appropriate to their workplace.
This article outlines the training program and reports on some preliminary evaluation. We report the effectiveness of this novel training program on (a) confidence in working with patients who may be depressed; (b) perceived barriers to the recognition and management of depression; and (c) the likelihood of responding to depression. Participants' perceptions and satisfaction with the training are also reported.
Thirty-six eye health practitioners including optometrists, orthoptists, ophthalmic nurses, and rehabilitation workers participated in this study. Table 1 outlines the participants' sociodemographic characteristics. Participants included both relatively new practitioners and practitioners with up to 30 years experience in eye care services.
Sociodemographic characteristics, professional background, and training and current employment were recorded.
Confidence in Recognizing and Responding to Depression in People with Vision Impairment
A measure to assess confidence in working with elderly people with depression was adapted for use in working with people with vision impairment based on our focus groups with eye health professionals.19,24 Items were reworded to refer to patients with vision impairment rather than “older people” and made relevant to the eye care setting rather than nursing home setting. Items concerning monitoring symptoms and distinguishing depression and dementia that were not relevant in this context were removed and new items concerning educating patients about depression and its treatment strategies were added. Participants responded to 14 items on a four-point scale (“not confident” to “very confident”) with a higher score representing greater confidence. For example, “In being able to recognize that a patient with vision impairment might be depressed, I feel … ”
Barriers to Recognition, Assessment, and Management of Depression
Adapted from an existing measure to assess barriers to working with depressed elderly patients,24 this scale includes 15 items that are rated on a four-point scale (“strongly disagree” to “strongly agree”) with higher scores representing greater perceived barriers. For example, “I don't have enough time to talk with patients to tell if they might be depressed.”
Responding to Depression
Participants were asked to rate the frequency of undertaking 14 actions if they suspect a patient to be depressed (e.g., “Discuss referral options with the patient”) using a four-point scale (“never” to “often”). Following reverse coding of one item (“Avoid discussing feelings”), a high score represents more frequent action.
Given our small sample size and use of new measures, Rasch analysis was used to determine the validity, reliability, and measurement characteristics of the above measures. Rasch analysis is a form of Item Response Theory, where the ordinal ratings of the questionnaire are transformed to estimates of interval measures. Winsteps (version 3.67) and the Andrich rating scale model were used to perform Rasch analysis.31,32 Measurement validity was assessed by appropriate use of response categories; substantial measurement precision of the scale, i.e., ability to distinguish appropriate levels of ability within the participants; adequate item fit statistics; and the extent to which the scale measures a single construct (unidimensionality). After scale refinement, person measures were extracted for further analysis.
Questions were devised to elicit participants' perceptions of the training program. Participants were asked to rate the format and delivery (seven items), content and materials (six items), and program impact (five items). Response format varied from dichotomous answers to four-point response scales as well as open-ended questions.
Ethical approval was received from the Human Research and Ethics Committee of the Royal Victorian Eye and Ear Hospital. Consultations with professional organisations and employing agencies were held to discuss the training program and applicability to staff. With management agreement the training program was offered on a voluntary basis to all staff in tertiary and community settings. Managers disseminated information about the training and encouraged staff attendance, and posters outlining the training content and date were distributed. All participants gave signed consent to participate in the study and were required to complete a questionnaire ∼2 weeks before attending the training program and a second questionnaire at the end of the last session.
The training program was delivered in 3 × 1.5-h group sessions held once a week for 3 consecutive weeks. The modules covered (1) understanding depression, (2) detecting depressive symptoms, and (3) developing and implementing referral pathways (Table 2). In addition to providing information, the training actively involved the attendees in group discussions and activities such as reviewing case studies and a depression quiz. Between sessions, attendees were encouraged to try out different tasks and to discuss their experiences with the group the following week. A range of resources were made available in the training such as draft referral letters, screening tools, and patient information packs.
Five training groups were conducted with a total of 50 participants. Three training groups were held with staff at the Royal Victorian Eye and Ear Hospital (n = 4, 6, 9), one group with staff from the Australian College of Optometry (n = 16), and another at a vision rehabilitation agency, Guide Dogs Victoria (n = 15). A total of 36 (72%) attendees completed both pre and post questionnaires. One participant did not complete a baseline questionnaire and 13 participants failed to return a follow-up questionnaire. These 13 non-responders were distributed across the training groups RVEEH (n = 4, 30.8%), Australian College of Optometry (n = 4, 30.8%) and Guide Dogs Victoria (n = 5, 38.5%), and included ophthalmic nurses (n = 2, 15.4%), optometrists (n = 3, 23.1%), orthoptists (n − 2, 15.4%) and orientation and mobility instructors (n = 5, 46.2%). A comment from an orientation and mobility instructor at Guide Dogs Victoria revealed that this participant did not attend following session one, since they worked with paediatric clients. There were no difference in age, gender or duration in eye care services between those who did not complete the follow-up questionnaire and those that did (p > 0.05). Further information on the number of sessions attended and reasons for not completing the follow-up questionnaire are not available.
Some refinements to the outcome measures were made to improve the psychometric properties. The “responding to depression” scale initially demonstrated disordered thresholds with participants unable to distinguish between response categories “never” and “rarely”; hence, these categories were collapsed. Misfitting items were then identified and removed (three items from the confidence scale, two items from the barriers scale, and six items from the responding to depression scale). The resulting measures showed excellent properties including substantial person separation reliability values ranging from 0.81 to 0.93. There was no evidence of multidimensionality, and the items showed good targeting. Person measures are expressed in logits (log of odds) that refers to the participants' perceived level of the trait relative to the required level by the items in the questionnaire. Mean person measures (±SD) at baseline were −1.39 (±1.97), 1.26 (±1.2) and −1.43 (±1.88) logits for the ‘Confidence in recognising and responding to depression in people with vision impairment’; ‘Barriers to recognition, assessment and management of depression’; and ‘Responding to depression’ scales, respectively. A positive mean value indicates that the sample mean level of the trait is higher than mean level of the trait required to undertake the items and a negative mean value indicates the reverse. Therefore, high scores represent high levels of confidence, higher levels of perceived barriers and greater action taken in response to depression respectively, for the ‘Confidence in recognising and responding to depression in people with vision impairment’; ‘Barriers to recognition, assessment and management of depression’; and ‘Responding to depression’ scales.
The person measures of pre and posttest are valid indicators over time if the item and scale calibrations do not change with time.33 To test the stability of calibrations, we tested differential item functioning (DIF) of the stacked data of pre and postresponses. DIF occurs when different subgroups of the sample respond differently to an individual item. We found no evidence of DIF for time (pre and posttest) for all three scales.
A one-way (preintervention vs. postintervention) repeated measures multivariate analysis of variance was conducted to determine the change after intervention on the person measures derived for the three dependent variables (confidence, perceived barriers, and responding to depression). The model was significant (F3,33 = 22.827, p < 0.001). Univariate analyses revealed that, after the training program, participants had significantly greater confidence in detecting depression (F1,35 = 93.45, p < 0.001), had significantly reduced perceived barriers to the recognition of depression (F1,35 = 19.45, p < 0.001), and reported that they were more likely to respond to depression when it is identified (F1,35 = 75.50, p < 0.001; Table 3).
Post hoc t-tests were conducted to determine which actions on the “responding to depression” scale changed significantly. Table 4 demonstrates that after the training, participants were more likely to engage in the majority of actions in response to depression. The strongest changes were that participants were more likely to refer the patient to self-help or support groups, use a depression screening tool, provide resources about depression and support options, and provide a referral to the patient's general practitioner after training (p < 0.001 for all). There was no change in likelihood of referring to a mental health service (p > 0.05).
The majority of participants attended all three sessions (n = 26, 72.2%) and reported that the number of sessions was “just right” (n = 32, 88.9%). Most felt that the duration of sessions was “just right” (n = 25, 69.4%) although a minority (n = 7, 19.4%) felt the sessions were “too short.” All participants who responded (n = 36, 100%) agreed that the training was well taught, and most (n = 34, 94.5%) reported that there was sufficient time for group discussion and that the assignments in between sessions enhanced the training. The majority agreed that the information was appropriate to their work roles (n = 34, 94.5%), that their patients would benefit from what they had learnt (n = 35, 97.2%) and that they would recommend the training to others (n = 36, 100%). When asked how they would improve the program, four participants stated they would like more information on treatments for depression, particularly more details and examples of psychological treatments, three participants suggested that the duration of the sessions should be extended, two participants requested more case studies, and one suggested a video. Two participants stated that additional practical sessions would be useful.
At the end of the program, 16 participants (44.4%) reported that they had started discussions with colleagues about developing local referral processes. The majority reported that they intended to use the patient resources (n = 34, 94.4%), referral letters (n = 29, 80.6%), and depression screening tools (n = 28, 77.8%) in their work.
This intervention is the first depression training program specifically designed for professionals working with people with vision impairment. Our results indicate that the training significantly improved participants' confidence in working with patients with depression; reduced perceived barriers; and increased the likelihood of responding to possible depression. These results are promising and indicate that this program, once evaluated using a randomized controlled trial design, could be effective in improving the management of depression in people with vision loss by eye care professionals.
Following the program staff were more likely to screen for depression, provide information and education about depression and make appropriate referrals to the clients GP. This is the most appropriate referral pathway in Australia since Medicare rebates for psychological services are available following GP assessment and referral.34 Identifying people with vision impairment and depressive symptoms within current services is the first step to managing depression; the second step is to ensure that care pathways lead to utilization of effective services. Research from other health areas has indicated that screening systems will only be effective when combined with subsequent provision of appropriate treatment.34 However, little is known about the use or effectiveness of existing psychological support services on levels of depression in people with vision impairment. It is not clear whether the existing community-based services are sufficient or whether specific interventions for people with vision impairment are required. Even when referral systems are in place, barriers to service uptake are likely to occur. For example, studies from oncology settings found that only 22% of patients who were offered psychosocial support following screening accepted a referral.35 Service uptake in that setting was associated with gender and level of depression.35 There is a need to determine the level of uptake of psychosocial support services in people with vision impairment, as well as identify factors associated with service utilization including system and patient barriers.
Participants' evaluation of the program additionally revealed that it was of sufficient duration and appropriate level although a longer more detailed program with practical sessions would be welcome by some staff. Participants reported that the three 1.5 hour sessions were considered sufficient to cover the necessary content. However it is not clear if this duration is brief enough to fit into the busy schedule of practitioners given that only 26 (72.2%) were able to actually attend all three sessions. The implementation of an extended version would need clear managerial support to allow staff attendance. Both smaller and larger groups were deemed to be acceptable by the participants, although the smaller groups allowed for longer and more detailed discussions. Whilst participants' evaluation was positive, it should be noted that 13 participants did not complete a follow-up questionnaire and it is unclear if this is due to inability to attend the sessions, lack of time to complete the survey or if these participants were less satisfied with the training.
Although highly promising, this preliminary study has a number of methodological limitations, which suggest that the results should be treated with caution at this stage. First, we did not have a control group to make comparisons with and, therefore, cannot firmly conclude that the changes identified are a result of the training or just simple time effects. Because a critical part of the training was to encourage and support staff to discuss and work with colleagues to develop and implement local referral pathways, it was not feasible to recruit a control group from the same organizations involved in the training study. Attempts made to recruit participants from other organizations met with limited success and resulted in too few control participants for analysis.
A second limitation of the study is that our evaluation was conducted immediately after the final session and was based on self-report alone. However, our results are consistent with other studies, which have found a positive impact of depression training in other health care areas on outcomes such as self-efficacy.24–27,36 We also demonstrated that after the training, participants reported that they were more likely to take a number of actions in response to a patient who may be depressed. However, it is unclear whether these effects will be sustained or result in actual change in practice. A longitudinal study is necessary to evaluate the impact of the training program. Such a study could assess change in practice in the longer term and verify self-report via patient notes or interviews. A case cross-over design would be useful to help determine change as a result of the training program or, if feasible, a randomized controlled trial, randomized by center would be ideal.
A third limitation of our study is that participants volunteered to take part in the training, often in a lunch time-slot or after hours, and our sample may therefore not be representative. It is possible that this volunteer group may be particularly enthusiastic and motivated to engage. It is important to note that no ophthalmologists volunteered to attend the training. This confirms findings from our earlier survey which suggested that ophthalmologists are less interested in depression training than other eye health professionals.20
Despite these limitations, this study suggests that a brief training program has the potential to increase the capacity of eye health and low vision rehabilitation professionals to detect and respond to depression in people with vision impairment. Clearly, further work is needed to examine the impact and sustainability of such training on practitioners' skill and actions and also to investigate the impact of referral pathways on patient outcomes.
We thank all participants who took part in this study. We also thank the following bodies who worked with us to organize the training: Australian College of Optometry; Guide Dogs Victoria; and Royal Victorian Eye and Ear Hospital.
Centre for Eye Research Australia
C/o the Royal Victorian Eye and Ear Hospital
Locked Bag 8, East Melbourne
Victoria 8002, Australia
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