Research projects

Uptake and outcomes of a referral pathway for people with vision impairment and depressive symptoms

Principal researchers

Dr Gwyneth Rees
Associate Professor Ecosse Lamoureux
Professor Jill Keeffe


Centre for Eye Research Australia



Award type

Beyond Blue Victorian Centre of Excellence

Project completion year


Project brief

Depression is a debilitating and serious health concern in Australia and affects approximately one in three individuals with low vision1. Compared to normally sighted individuals of a similar age, rates of depression are estimated to be at least double in older adults with low vision2. For a person with vision impairment, depression can lead to heightened levels of disability and functional decline. Early identification and management of depressive symptoms in people with vision impairment is therefore critical in reducing and preventing excess disability3. However, depression most often remains undetected and untreated in people with vision impairment.

Aims and objectives

The aims of this project were to:

  • develop and evaluate a model whereby depressive symptoms could be detected in adults with low vision
  • explore the impact of existing community-based services on levels of depression and quality of life in patients with vision impairment
  • determine if current services are sufficient, or if there is a need to develop specific interventions for this group.

This is the first time worldwide a study has evaluated existing services on depressive symptoms in people with vision impairment. The main objectives were to:

  • develop a new depression screening and referral program for low vision rehabilitation staff
  • explore patients’ acceptability of this novel depression screening model
  • determine the level and nature of service uptake and barriers experienced by patients
  • explore patients’ views and satisfaction with the referral process and services received
  • identify patients’ characteristics associated with service utilisation
  • explore CALD patients’ views on service needs and delivery.


This is a prospective longitudinal study in which participants completed telephone-administered questionnaires at baseline, three and six months follow-up. Participants were recruited from Vision Australia and the Royal Victorian Eye and Ear Hospital (RVEEH).

Adults attending tertiary ophthalmic and low vision rehabilitation appointments were asked to complete a two-item depression screening tool, the Patient Health Questionnaire-2. Those with a positive score were referred to their GP to discuss depression, and were provided with educational material about depression and available community services.

After completing the screening tool, all patients were invited to take part in the study. Those who consented completed a baseline questionnaire, administered via telephone, which determined the acceptability of the depression screening model and preferences for psychological support services. Participants were followed up at three and six months. Follow-up telephone interviews measured participants’ experience and satisfaction with both the referral pathway and any services they received, their perception of the impact the intervention had on their wellbeing, perceived barriers to service uptake and their unmet needs/suggestions for improvement.

The researchers developed an ‘Emotional Support Competency’ professional development program in collaboration with Vision Australia. This training includes a depression screening and referral process outlined in the Research Plan and was rolled out to all Vision Australia staff in Victoria, New South Wales and Queensland over May-July 2010.

To evaluate the training outcomes, 338 Vision Australia staff completed a pre-post questionnaire. Twenty-two Vision Australia staff took part in semi-structured interviews. To determine the rate of depressive symptoms and acceptability of depression screening in low vision and eye care services, 253 participants were invited to take part in the study and screened for depression (target=300).

Key findings

  •  As a result of the emotional support training throughout, Vision Australia staff were more confident in recognising and responding to depression; reported to be more likely to identify depression in patients; and more likely to provide information about depression and make appropriate referrals to a client’s GP following the training.
  • Depressive symptoms were found to be common among adults accessing low vision and eye services. 41 per cent of participants screened positive for depressive symptoms.
  • 87 per cent of participants thought it was a good idea to screen for depression in low vision rehabilitation and eye care services.
  • 96 per cent of participants did not feel embarrassed being screened for depression using this tool.
  • 95 per cent of participants did not feel it was upsetting or annoying to be screened for depression.
  • 94 per cent of participants did not feel uncomfortable being screened for depression.
  • 68 per cent of participants said they wanted help in the form of emotional support.
  • More than 70 per cent of participants said they would be happy to receive ‘talking’ therapy from a therapist over the telephone or in their own home.
  • 52 per cent of participants favoured individual ‘talking’ therapy compared to 11 per cent who favoured anti-depressant medication.
  • Of those participants who screened positive on the depression screening tool, less than a third (31.5 per cent) accepted a referral to their GP for further assessment and support.

Practical outcomes

As part of this project, Vision Australia integrated the depression training program into an ‘Emotional Support Competency’ (ESC) professional development program. This is now a compulsory training module undertaken by all staff that has client contact. This is the first time a depression screening program has been introduced in a low vision rehabilitation setting worldwide.

Translation of the findings into practice

The work conducted on this project has achieved significant ongoing change in Vision Australia’s services. All staff with client contact are now required to undertake the ESC professional development program. In addition, the Patient Health Questionnaire-2 depression screening instrument has been embedded into Vision Australia’s workflow and will be an ongoing component of new intake assessment for all clients.


1 Horowitz A. The prevalence and consequences of vision impairment in later life. Top Geriatric Rehabil 2004; 20 (3): 185-95.
2 Burmedi D, Becker S, Heyl V, Wahl HW, Himmelsbach I. (2002) Emotional and social consequences of age related low vision. A narrative review. Visual Impairment Research, 4(1)47-71.
3 Rovner, B.W., R.J. Casten, and W.S. Tasman, Effect of depression on vision function in age-related macular degeneration. Archives of Ophthalmology, 2002. 120(8): p. 1041-1044.


Rees G, Holloway EE, Craig G, Hepi N, Coad S, Keeffe JE, Lamoureux EL. Screening for depression: integrating training into the professional development program for low vision rehabilitation staff. Clinical and Experimental Ophthamology, 2012, 7 Mar, doi: 10.1111/j.1442-9071.2012.02779.x

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