A holistic approach to health means that psychosocial needs are to be responded to as well as ocular needs (Raasch, Leat, Kleinstein, Bullimore, & Cutter, 1997; Spaeth, 1997). One previous review that was both systematic and reviewed all visual impairment types was conducted by a German research team who reviewed quantitative studies of older people published between 1980 and the summer of 2001 (Burmedi, Becker, Heyl, Wahl, & Himmelsbach, 2002). Burmedi et al. reported that vision loss was associated with depression, poorer quality of life, and reduced social activity; that social support acted as a buffer against depression, with children and friends being important providers of support; but the association between vision loss and loneliness and broader measures of social inclusion was unclear.

Due to the importance of vision loss in older people, given its high prevalence and associated reduction in psychosocial well-being, the purpose of this article is to extend and enhance the review of Burmedi et al. (2002) with an update of the evidence of the psychosocial impact of vision loss in older people and extending this with an evaluation of interventions that aim to reduce the psychosocial consequences of vision loss.

Method

Using established search terms (Burmedi et al., 2002), PsycINFO and Medline were searched electronically for quantitative studies published in English from 2001 – July 2008. The inclusion criteria were that studies recruited older adults (sample mean age of 60+, or at least 66% of the sample aged 60+), who had a visual impairment or were part of the support network (e.g. spouse of an individual with vision loss), and provided quantitative data on one or more of seven outcome measures: depression / mental health, anxiety, quality of life / well-being, social functioning, loneliness, or social support. Further papers were identified from the reference lists of papers retrieved and previous literature reviews, and a request for papers from members of the British Society of Gerontology and the Mental Health Practice and Aging interest group of the Gerontological Society of America. Study quality was evaluated using a modified Downs and Black’s (1998) score, with items assessing transparency in methodology, prevention of bias, and clarity of presentation of results. Intervention studies seeking to improve psychosocial well-being with low quality ratings were included, because of our interest in this area and relatively scarce evidence, but we excluded other studies that were rated with a low quality score (0-8/18).

Measures of effect size against a control group including odds ratios (OR) are reported, and where these values were not reported mean differences (MD) between groups on mean scores or percentage points are provided with an indication of the total points on the scale if provided. Where more than one study used a measurement scale aggregate values were calculated to provide the average, minimum, and maximum scores.  

Results

We identified 174 papers for review with a total of 288 outcomes analysed (see Table 1). Seven key points were drawn from the results:

Table 1. Categorisation and Number of Outcome Measures Reviewed

Notes: 1. Total number of outcomes for analysis from the 174 papers; a Word file of tables that summarise the studies reviewed and provides a full reference list is available from the first author upon request (pp. 182). 2. Eight studies measured both depression (n = 46) and mental health (n = 52). 3. Included 16 rehabilitation and 14 psychosocial interventions.

1. Older people with vision loss are more at risk of reporting symptoms of depression and lower mental health, and being diagnosed with clinical depression than their sighted peers.

Nineteen of 22 studies suggested depressive symptoms to be prevalent in people with vision loss at an average rate of 23.4% (range 3-43%),¹ and six studies suggested that depressive symptoms are more likely in those with vision loss than controls (average OR = 1.88, range OR = 1.26-2.38) (Capella-McDonnall, 2005; Chou, 2008; Chou & Chi, 2004; Crews & Campbell, 2004; Evans, Fletcher, & Wormald, 2007; Tsai et al., 2003). Five studies using a range of clinical measures found the proportion of people with vision loss diagnosed as depressed was on average 20.57% (range 4.2-53.0%) (Bramley, Peeples, Walt, Juhasz, & Hansen, 2008; Horowitz, Reinhardt, & Kennedy, 2005b; Lupsakko, Mäntyjärvi, Kautiaininen, & Sulkava, 2002; Tournier, Moride, Ducruet, Moshyk, & Rochon, 2008; Wilson et al., 2002) and in three studies those with vision loss were more likely than controls to be diagnosed with depression (average OR = 1.53, range OR = 1.20-2.15) (Bramley et al., 2008; Javitt, Zhou, & Willke, 2007; Wallhagen, Strawbridge, Shema, Kurata, & Kaplan, 2001). With the National Eye Institute-Visual Function Questionnaire (NEI-VFQ), reduced mental health was associated with vision loss in 19 studies (average MD = 20.17/100, range MD = 2.7-48.98/100),² with an average mean score of 65.09/100 (n = 9, range M = 33.9-89.3/100).

2. Visual functioning rather than vision status has a stronger relationship with depressive symptoms

Severity of vision loss was not consistently correlated with greater prevalence of symptoms of depression, lower mental health, or anxiety. In contrast, the risk of depressive symptoms was higher in those with worse visual functioning (average OR = 4.25; range OR = 1.91-8.3) (Iliffe et al., 2005; Owsley & McGwin Jr, 2004; Rovner & Casten, 2001).

3. Social functioning is likely to be reduced in individuals with vision loss, but not social network size or social activity.

With the NEI-VFQ, values in social functioning were on average 81.36/100 (range 58-100/100), and lower than sighted peers with an average mean difference of 18.37/100 (range MD = 3.40-38/100).³ Though, apart from two studies, there was no association between visual impairment and social network size and social activity (Cruice, Worrall, & Hickson, 2005; DeCarlo, Scilley, Wells, & Owsley, 2003; Jang et al., 2003; Lind et al., 2003; Wahl, Schilling, Becker, & Burmedi, 2003).

4. Anxiety was not more prevalent and quality of life was not consistently reduced in persons with visual impairment.

Despite the above findings in relation to depression, mental health, and social functioning, the prevalence of symptoms of anxiety in people with vision loss in five studies was on average 19.32% (range 2.3-39.5%), which was at a similar rate to that of controls (MD = 0.9-2.0/21) (Lotery, Xu, Zlatava, & Loftus, 2007; Soubrane et al., 2007). In addition, there were mixed findings as to whether quality of life (measured in terms of utility values, role limitations due to emotional difficulties, emotional distress, impact of vision loss, and mood) is reduced in persons with visual impairment.

5. Loneliness is under-researched but one study suggested a higher prevalence of mild loneliness in individuals with vision loss.

The one study that used a validated scale found the prevalence of loneliness to be higher than found previously in the general older population (54% vs. 44%) (Verstraten, Brinkmann, Stevens, & Schouten, 2005).

6. Social support buffers against the presence of depressive symptoms but there is mixed evidence for social support to facilitate adaptation to vision loss and psychological well-being.

Consistent with previous studies with the wider population, social support was found to buffer against depression (Horowitz, Reinhardt, Boerner, & Travis, 2003; McIlvane & Reinhardt, 2001; Reinhardt, Boerner, & Horowitz, 2006). For example, perceived adequacy of support from family and friends reduced the risk of diagnosis of subthreshold (OR = 0.77) and major (OR = 0.68) depression (Horowitz et al., 2005b). However, for adaptation to vision loss and psychological well-being, the evidence was mixed for the facilitating effect of being married or having a large / supportive social network.

7. Interventions that address psychosocial needs directly are more effective than rehabilitation that addresses them indirectly through instrumental support.

For rehabilitation, low vision services are designed to rehabilitate people with vision loss by training clients to make use of their residual vision and learn how to perform tasks without sight. Eleven studies using a range of outcome measures suggested that in isolation, rehabilitation is not sufficient in supporting older people with their psychosocial needs, with up to only 12% of the variance in depressive symptoms explained.⁴

A randomised controlled trial (RCT) of self-management training found that at six months clinical diagnoses of depression were prevented (risk ratio = 0.49) (Brody, Roch-Levecq, Thomas, Kaplan, & Brown, 2005). Another RCT showed that a problem-solving intervention prevented depression (11.6% vs. 23.2%, OR = 0.43), and the number of relinquished activities mediated the effect on preventing depression, but that the intervention lost its effectiveness at six months (Rovner & Casten, 2008).

Discussion

Implications for Practice
Those with relatively mild visual impairment may still require emotional support in adjusting to their vision loss, particularly with preventing and / or treating depression. In conjunction with rehabilitation to meet physical needs such as mobility, emotional needs should also be considered and perhaps referral to formal counselling or group-based therapeutic interventions may be appropriate, in addition to any informal support received from healthcare professionals and family and friends. However, currently there is insufficient evidence to recommend a particular form of emotional support.

Directions for Future Research
Further research is required to understand the longitudinal pattern of reduced psychosocial well-being in people with vision loss, against a control group, and with covariates controlled. Whilst depression has been placed on the research agenda for geriatric ophthalmology (Lee & Coleman, 2004) further research would benefit from continued attention to wider psychosocial indicators of well-being.

Previous studies have found equivocal results for whether people with vision loss are more likely to be lonely (Burmedi et al., 2002), and unfortunately this area is under researched. Further research is also required to determine the role of personality in adaptation to vision loss, qualitatively explore the experience of reduced psychosocial well-being, and clarify the intra- and inter-relationships of variables such as the relation between social functioning and loneliness, and between different measures of social functioning. Further work is also required to develop effective interventions for reducing the psychosocial burden of vision loss, determine their best timing and format, and to assess their cost effectiveness, as no study measured the cost of an intervention or measured its effectiveness beyond six months.

In terms of which outcome measure(s) to use in assessing psychosocial impact, the NEI-VFQ appears to have most support for its psychometric properties (Mangione et al., 2001), and in particular the Rasch revised version (Langelaan et al., 2007; Massof & Fletcher, 2001). Indeed, the generic Short Form survey was found to be less sensitive than the vision-specific NEI-VFQ in identifying the relationship between vision loss and lower levels of mental health and social functioning. However, the NEI-VFQ only provides subscale measures for mental health and social functioning, and does not provide subscales for other psychosocial factors such as depression, anxiety, and loneliness.

Conclusion
This review has identified that a significant minority of people with vision loss can report reduced levels of psychosocial well-being in the areas of depression, mental health, and social functioning, but there was weak evidence for anxiety to be more prevalent and for reduced scores on measures of quality of life. Further, we identified that social support and interventions can help prevent or alleviate the psychosocial impact of vision loss. Future research is required to determine the longitudinal pattern of reduced psychosocial well-being and the intra- and inter-relations among variables, and to develop and evaluate interventions designed to reduce the psychosocial burden of vision loss.

Notes
1. (Augustin et al., 2007; Capella-McDonnall, 2005; Casten, Rovner, & Edmonds, 2002; Chou & Chi, 2004; Crews & Campbell, 2004; Dreer, Elliott, Fletcher, & Swanson, 2005; Hayman et al., 2007; Horowitz, Reinhardt, & Boerner, 2005a; Jackson, Bassett, Nirmalan, & Sayre, 2007; Lee, Beaver, Jogerst, & Daly, 2003; Owsley et al., 2006; Reinhardt, 2001; Robertson, Burden, & Burden, 2006; Rovner & Casten, 2001; Rovner, Casten, William, & Tasman, 2002; Submacular Surgery Trials Research Group [SST], 2004a; 2004b; 2004d).

2. (Age-Related Eye Disease Study Research Group [AREDS], 2005; Cahill, Banks, Stinnett, & Toth, 2005; Cahill, Stinnett, Banks, Freedman, & Toth, 2005; Coleman, Yu, Keeler, & Mangione, 2006; Fuhr, Holmes, Fletcher, Swanson, & Kuyk, 2003; Ghazi-Nouri, Tranos, Rubin, Adams, & Charteris, 2006; Hariprasad et al., 2008; Hyman, Komaroff, Heijl, Bengtsson, & Leske, 2005; Lotery et al., 2007; Lüke, Ziemssen, Bartz-Schmidt, & Gelisken, 2007; Mangione et al., 2001; Nordmann, Auzanneau, Ricard, & Berdeaux, 2003; 2004; Owsley et al., 2006; Rossi, Milano, & Tinelli, 2003; SST, 2003; 2004a; 2004c; Wu, Hennis, Nemesure, & Leske, 2008).

3. (AREDS, 2005; Berdeaux, Nordmann, Colin, & Arnould, 2005; Cahill et al., 2005; Clemons, Chew, Bressler, & McBee, 2003; Deramo, Cox, Syed, Lee, & Fekrat, 2003; Lotery et al., 2007; Mangione et al., 2001; Nordmann et al., 2003; 2004; Rossi et al., 2003; Scilley, DeCarlo, Wells, & Owsley, 2004; SST, 2003; Tranos et al., 2004; Wu et al., 2008).

4. (Boerner, 2004; Boerner & Reinhardt, 2003; Boerner, Reinhardt, & Horowitz, 2006; Brennan, 2002; Hinds et al., 2003; Horowitz, Brennan, Reinhardt, & MacMillan, 2006; Horowitz et al., 2005a; 2003; Kuyk et al., 2008; La Grow, 2004; Pankow, Luchins, Studebaker, & Chettleburgh, 2004; Reeves, Harper, & Russell, 2004; Scilley et al., 2004; Strong, Jutai, Bevers, Hartley, & Plotkin, 2003; Tolman, Hill, Kleinschmidt, & Gregg, 2005).

Acknowledgements
We thank the project advisory group for their comments on a summary presentation of the initial findings of this review: Iain Hopkin (Thomas Pocklington Trust R&D Committee), Martin Leyland (Royal Berkshire NHS Foundation Trust, West Berkshire Community Hospital, and Oxford Eye Hospital), Angela McCullagh (Thomas Pocklington Trust), Mary Norowzian (RNIB), and Femi Nzegwu (Guide Dogs).

Funding
This review was commissioned and funded by the Thomas Pocklington Trust whilst the first author was at the Institute of Health Sciences, University of Reading, and the third author was at the School of Health and Social Care, University of Reading [grant number B10548].

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