Research projects

Integrated depression management: A trial of a new model of care in low vision

Principal researchers

Dr Gwyn Rees 1,2
Professor Jill Keeffe1
Dr Robin Casten3
Dr Mark Hegel4
Associate Professor Eric Finkelstein5
Dr Xie Jing1
Associate Professor David Mellor6

Institution/ARC partners

1 The University of Melbourne
2 Centre for Eye Research Australia
3 Thomas Jefferson University
4 Dartmouth Medical School
5 Duke-NUS Graduate Medical School Singapore
6 Deakin University

Funding

$75,000 (plus in-kind $64,500)

Co-funded with

ARC Linkage Grant $394,000
Vision Australia $30,000 (plus in-kind $569,431)

Award type

ARC Linkage grant

Project completion year

2014

Project brief

The purpose of this project is to integrate depression management into Vision Australia services and evaluate the impact of this new model of care. The researchers anticipate that this new approach will lead to sustained improvements in clients’ quality of life.

Depression is very common in people with vision impairment and leads to further functional decline. However, only a minority of people with vision impairment gain access to psychological support services. Together with Vision Australia and beyondblue, we will examine the impact of different depression management options for people with vision loss. We anticipate that a new integrated model of care, in which Vision Australia staff are trained to deliver depression treatment as part of low vision rehabilitation, will improve client outcomes in a cost-effective manner compared to usual. This project will place Australia at the forefront of low vision care and provide an innovative service delivery model suitable for other health care areas.

Aims and background

Depression is a common problem in people with vision impairment and results in heightened levels of disability and functional decline. Despite the availability of evidence-based interventions for depression, it is rarely managed within this group. Psychological services in Australia are currently segregated from physical health care and focus predominately on crisis response rather than early intervention.

Project aims

Researchers will trial a new integrated model of care within low vision rehabilitation services and compare client outcomes to current practice. They aim to integrate an evidence-based psychological therapy, ‘problem-solving therapy for primary care’ (PST-PC), into the low vision rehabilitation services provided by Vision Australia. They will train staff to deliver PST-PC, as part of the rehabilitation program, to those clients identified as showing depressive symptoms. This new system is designed to ensure that effective psychological interventions are available and accessible at an early stage to those clients in need. They aim to determine, using a randomised controlled trial, the impact of this new integrated system on short- and long-term client outcomes compared to usual care. The researchers also aim to examine the cost-effectiveness of this new model.

Hypotheses

Compared to those receiving usual care, the clients who receive PST-PC will:

  • show a lower rate of depressive disorder and significantly reduced depressive symptoms at follow-up (_3 months)
  • show significant improvements in problem-solving and coping, quality of life and reduced depressive behaviours at follow-up (_3 months)
  • maintain these benefits six and 12 months after treatment
  • demonstrate that the integrated model is cost-effective compared with usual care.

Significance and innovation

Vision impairment is a common problem in Australia and our ageing population means that the number of Australians with vision impairment is projected to almost double to a million people by 2024. Rates of depression are estimated to be at least double in older adults with low vision, compared to sighted individuals of similar age. Depression further increases the burden on individuals and their families and results in huge additional costs to the health care system. Early identification and management of depressive symptoms in people with vision impairment is therefore critical in reducing and preventing excess disability. However, depression most often remains undetected and untreated in people with vision impairment.

This project will place Australia at the forefront of low vision care, through the provision of psychological treatment within a program of rehabilitation for physical disability. Specifically, it will provide the world’s first low vision rehabilitation system whereby depression is identified at an early stage and effectively managed. In this project we will also determine whether staff can be trained to deliver an effective depression treatment in a cost-effective manner. We predict that, compared to the current system, this new integrated model will not only be more accessible and acceptable to clients, resulting in improved client outcomes, but will also be able to prevent the development of depressive disorders in this high risk group, thus reducing the demand on existing community-based resources.

In Australia, it has been documented that there is a lack of psychologists skilled in working with older adults. Furthermore, in rural areas the lack of mental health professionals working in early intervention and peoples’ reluctance to accept specialist referrals are two major help-seeking barriers. This project takes an innovative approach to overcoming the practical barriers and stigma attached to psychological referrals by training vision rehabilitation staff from both metropolitan and regional centres across three states (VIC, NSW QLD) and two territories (ACT and NT) to deliver evidence-based psychological techniques to improve the mental health of the clients they care for. This project clearly addresses the National Research Priority Goal of ‘ageing well, ageing productively’.

This project not only provides a demonstration of a new way of working within low vision services, but will also serve as a health service delivery model within Australia and internationally, suitable for application to other chronic health conditions in which depression is also a pressing issue, such as diabetes, heart disease and oncology.

Approach and training

Design

A prospective, longitudinal, randomised controlled trial of the new integrated model compared to usual care will be conducted. Participants will be randomised to receive either PST-PC as an integrated component of their rehabilitation or usual care. Assessments will take place at baseline and three months to determine initial effects. Assessments at six and 12 months will be conducted to determine if changes are sustained in the longer term.

Participants and procedures

In order to be eligible, participants must: show at least minimal depressive symptoms (assessed by the Patient Health Questionnaire-9 [PHQ-9]); not currently be receiving any form of treatment for depression, including antidepressants; be 18 years or older; have visual acuity (<6/12 in the better eye with habitual correction); live independently in the community; speak English; have adequate hearing to respond to normal conversation; have no cognitive impairment (as assessed with the 6-item cognitive impairment test).

Recruitment: Participants will be recruited from Vision Australia centres across VIC, NSW, QLD, ACT and NT. Potential participants will be identified by Vision Australia staff during the depression screening process using a brief, two-question depression screening tool (PHQ-2). A group of 38 potential participants will be contacted by the research team, who will check eligibility criteria, gain consent from eligible participants and arrange interview times.

Randomisation and data collection: All interviews will be conducted over the phone by trained research assistants using a computer-assisted interview. Baseline interviews will be collected prior to randomisation.

Following the baseline assessment, participants will be allocated to the intervention or control groups based on the code contained within the next sequential sealed envelope. Follow-up interviews will be conducted by research staff masked to participant allocation. Breaches of masking will be assessed and reasons obtained. Assessment of visual acuity will take place at Vision Australia at each time-point.

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