BackgroundClinically significant depressive symptoms are prevalent in people attending low vision clinics and often go undetected. The Low Vision Service Wales (LVSW) plans to introduce depression screening and management pathways. Prior to implementation there is an unmet need to understand how eye care practitioners providing the service currently address depression with patients, and the characteristics and beliefs that influence their practice.MethodsA mixed methods convergent design was employed. Twelve low vision practitioners were purposively selected to engage in individual semi-structured interviews which were analysed using thematic analysis. A further 167 practitioners were invited to complete a questionnaire assessing professional background, current practice, confidence and perceived barriers in working with people with low vision and suspected depression. Multiple regression analyses were performed to determine the characteristics related to the Rasch-transformed questionnaire scores.ResultsOf the 122 practitioners that responded to the questionnaire, 33% aimed to identify depression in patients, and those who were more confident were more likely to do so. Those who scored higher on the perceived barriers scale and lower on confidence were less likely to report acting in response to suspected depression (all p < 0.05). Three qualitative themes were identified; depression is an understandable response to low vision, patients themselves are a barrier to addressing depression and practitioners lacked confidence in their knowledge and skills to address depression. The qualitative data largely expanded the quantitative findings.ConclusionsPractitioners viewed their own lack of knowledge and confidence as a barrier to the identification and management of depression and expressed a need for training prior to the implementation of service changes. The study findings will help to inform the development of a training programme to support low vision practitioners and those working with other chronic illness in Wales, and internationally, in the identification and management of people with depression.

Citation: Nollett CL, Bray N, Bunce C, et al. Depression in visual impairment trial (DEPVIT): a randomized clinical trial of depression treatments in people with low vision. Invest Ophthalmol Vis Sci. 2016;57:4247-4254. DOI:10.1167/iovs.16-19345 PURPOSE. The purpose of this study was to compare two interventions for depression, problem solving treatment (PST) and referral to the patient's physician, with a waiting-list control group in people with sight loss and depressive symptoms.METHODS. This was an assessor-masked, exploratory, multicenter, randomized clinical trial, with concurrent economic analysis. Of 1008 consecutive attendees at 14 low-vision rehabilitation centers in Britain, 43% (n ¼ 430) screened positive for depressive symptoms on the Geriatric Depression Scale and 85 of these attendees participated in the trial. Eligible participants were randomized in the ratio 1:1:1 to PST, referral to their physician, or a waitinglist control arm. PST is a manualized talking intervention delivered by a trained therapist who teaches people over six to eight sessions to implement a seven-step method for solving their problems. Referral to the physician involved sending a referral letter to the person's physician, encouraging him or her to consider treatment according to the stepped care protocol recommended by the U.K.'s National Institute of Health and Care Excellence. The primary outcome was change in depressive symptoms (6 months after baseline) as determined by the Beck Depression Inventory.RESULTS. At 6 months, Beck Depression Inventory scores reduced by 1.05 (SD 8.85), 2.11 (SD 7.60), and 2.68 (SD 7.93) in the waiting-list control, referral, and PST arms, respectively. The cost per patient of the PST intervention was £1176 in Wales and £1296 in London.CONCLUSIONS. Depressive symptoms improved most in the PST group and least in the control group. However, the change was small and the uncertainty of the measurements relatively large.Keywords: low vision, depression, clinical trial, mental health, intervention A growing body of evidence suggests that low vision is associated with depression. Results from several studies in North America suggest that the prevalence of depression and depressive symptoms in those accessing visual rehabilitation centers ranges from 22% to 38%. 1-4 Untreated depression has a profound negative impact on quality of life and reduces life expectancy. [5][6][7] What is less clear, however, is how to treat the depressive symptoms in this vulnerable group.In otherwise healthy adults, about 50% of those who receive psychological treatments or antidepressants recover fully. 8,9 However, the effects of depression treatment in people with chronic health conditions are somewhat less clear. For example, a recent meta-analysis of psychological interventions for depression in people with coronary heart disease concluded that although psychological treatments work, the effects are only small (typical effect size 0.3). 10A myriad of psychological interventions have been developed for depression,...

ObjectiveTo identify the risk factors for significant depressive symptoms in people with visual impairment in England and Wales to provide information on who is most at risk and to whom support services could be targeted in future.DesignA cross-sectional study using baseline data from a pragmatic randomised controlled trial.Setting and participants990 participants aged 18 or over attending 1 of 14 low-vision rehabilitation primary care optometry-based clinics in South Wales or two hospital clinics in London.Outcome measureA score of ≥6 on the Geriatric Depression Scale-15 was classed as clinically significant depressive symptoms.ResultsIn a multivariable logistic regression model, significant depressive symptoms were associated with age (adjusted OR (AOR)=0.82, 95% CI: 0.66 to 0.90, p<0.001), ethnicity (AOR non-white compared with white=1.72, 95% CI: 1.05 to 2.81, p=0.031), total number of eye conditions (AOR for two vs one condition=0.98, 95% CI: 0.67 to 1.43; three or more vs one condition=0.34, 95% CI: 0.15 to 0.75, p=0.026), self-reported health (AOR for excellent vs poor=0.01, 95% CI: 0.00 to 0.12; very good vs poor=0.06, 95% CI: 0.03 to 0.13; good vs poor=0.14, 95% CI: 0.08 to 0.24; fair vs poor=0.28, 95% CI: 0.18 to 0.46, p<0.001) and self-reported visual functioning (AOR=1.45, 95% CI: 1.31 to 1.61, p<0.001).ConclusionYounger age, a non-white ethnicity, fewer eye conditions and poorer self-reported health and visual function are risk factors for significant depressive symptoms in this population.Trial registration numberISRCTN46824140; Pre-results.

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BackgroundThe prevalence of depression in people with a visual disability is high but screening for depression and referral for treatment is not yet an integral part of visual rehabilitation service provision. One reason for this may be that there is no good evidence about the effectiveness of treatments in this patient group. This study is the first to evaluate the effect of depression treatments on people with a visual impairment and co morbid depression.Methods /designThe study is an exploratory, multicentre, individually randomised waiting list controlled trial. Participants will be randomised to receive Problem Solving Therapy (PST), a ‘referral to the GP’ requesting treatment according to the NICE’s ‘stepped care’ recommendations or the waiting list arm of the trial. The primary outcome measure is change (from randomisation) in depressive symptoms as measured by the Beck’s Depression Inventory (BDI-II) at 6 months. Secondary outcomes include change in depressive symptoms at 3 months, change in visual function as measured with the near vision subscale of the VFQ-48 and 7 item NEI-VFQ at 3 and 6 months, change in generic health related quality of life (EQ5D), the costs associated with PST, estimates of incremental cost effectiveness, and recruitment rate estimation.DiscussionDepression is prevalent in people with disabling visual impairment. This exploratory study will establish depression screening and referral for treatment in visual rehabilitation clinics in the UK. It will be the first to explore the efficacy of PST and the effectiveness of NICE’s ‘stepped care’ approach to the treatment of depression in people with a visual impairment.Trial registrationISRCTN46824140

ObjectivesTo determine the clinical effectiveness and cost effectiveness of including emollient bath additives in the management of eczema in children.DesignPragmatic randomised open label superiority trial with two parallel groups.Setting96 general practices in Wales and western and southern England.Participants483 children aged 1 to 11 years, fulfilling UK diagnostic criteria for atopic dermatitis. Children with very mild eczema and children who bathed less than once weekly were excluded.InterventionsParticipants in the intervention group were prescribed emollient bath additives by their usual clinical team to be used regularly for 12 months. The control group were asked to use no bath additives for 12 months. Both groups continued with standard eczema management, including leave-on emollients, and caregivers were given standardised advice on how to wash participants.Main outcome measuresThe primary outcome was eczema control measured by the patient oriented eczema measure (POEM, scores 0-7 mild, 8-16 moderate, 17-28 severe) weekly for 16 weeks. Secondary outcomes were eczema severity over one year (monthly POEM score from baseline to 52 weeks), number of eczema exacerbations resulting in primary healthcare consultation, disease specific quality of life (dermatitis family impact), generic quality of life (child health utility-9D), utilisation of resources, and type and quantity of topical corticosteroid or topical calcineurin inhibitors prescribed.Results483 children were randomised and one child was withdrawn, leaving 482 children in the trial: 51% were girls (244/482), 84% were of white ethnicity (447/470), and the mean age was 5 years. 96% (461/482) of participants completed at least one post-baseline POEM, so were included in the analysis, and 77% (370/482) completed questionnaires for more than 80% of the time points for the primary outcome (12/16 weekly questionnaires to 16 weeks). The mean baseline POEM score was 9.5 (SD 5.7) in the bath additives group and 10.1 (SD 5.8) in the no bath additives group. The mean POEM score over the 16 week period was 7.5 (SD. 6.0) in the bath additives group and 8.4 (SD 6.0) in the no bath additives group. No statistically significant difference was found in weekly POEM scores between groups over 16 weeks. After controlling for baseline severity and confounders (ethnicity, topical corticosteroid use, soap substitute use) and allowing for clustering of participants within centres and responses within participants over time, POEM scores in the no bath additives group were 0.41 points higher than in the bath additives group (95% confidence interval −0.27 to 1.10), below the published minimal clinically important difference for POEM of 3 points. The groups did not differ in secondary outcomes, economic outcomes, or adverse effects.ConclusionsThis trial found no evidence of clinical benefit from including emollient bath additives in the standard management of eczema in children. Further research is needed into optimal regimens for leave-on emollient and soap substitutes.Trial registrationCurrent Controlled Trials ISRCTN84102309.

Don't forget EDNOS (eating disorder not otherwise specified): patterns of service use in an eating disorders service AIMS AND METHODThe aim of the study was to track service consumption in adult referrals to a specialised NHS eating disorders service over a 3-year period. We examined clinical records of a year's cohort (1999) of 147 referrals (96% female) assessed from the local catchment area. RESULTSThe most common diagnostic group (42.8%) presented with some form of eating disorder not otherwise specified (EDNOS). There was no significant relationship between diagnosis and service consumption, so that full syndrome eating disorders were no more labour-intensive overall than EDNOS patients. Indeed, EDNOS patients accounted for 50% of all outpatient appointments and over a half of all in-patient days. CLINICAL IMPLICATIONSThe results suggest that those planning services for eating disorders need to take into account the substantial demand from EDNOS patients.

Background: Undetected depression is common in people with low vision and depression screening has been recommended. However, depression screening is a complex procedure for which low vision practitioners need training. This study examined the integration of routine depression screening, using two questions, and referral pathways into a national low vision service in Wales at 6 months following practitioner training, and identified key barriers to implementation. Methods: This pre-post single group study employed a convergent mixed methods design to collect quantitative questionnaire and qualitative interview data on low vision practitioners' clinical practice and perceived barriers to implementing depression screening. Forty practitioners completed questionnaires pre-, immediately post-and 6 months post-training and nine engaged in interviews 6 months post-training. Ordinal questionnaire scores were Rasch-transformed into interval-level data before linear regression analyses were performed to determine the change in scores over time and the association between perceived barriers and clinical practice. Thematic Analysis was applied to the interviews and the narrative results merged with the questionnaire findings. Results: Before training, only one third of practitioners (n = 15) identified depression in low vision patients, increasing to over 90% (n = 37) at 6 months post-training, with a corresponding increase in those using validated depression screening questions from 10% (n = 4) to 80% (n = 32). Six months post-training, practitioners reported taking significantly more action in response to suspected depression (difference in means = 2.77, 95% CI 1.93 to 3.61, p < 0.001) and perceived less barriers to addressing depression (difference in means = − 0.95, 95% CI − 1.32 to − 0.59, p < 0.001). However, the screening questions were not used consistently. Some barriers to implementation remained, including perceived patient reluctance to discuss depression, time constraints and lack of confidence in addressing depression. Conclusions: The introduction of depression screening service guidelines and training successfully increased the number of low vision practitioners identifying and addressing depression. However, standardized screening of all low vision attendees has not yet been achieved and several barriers remain. Healthcare services need to address these barriers when considering mental health screening, and further research could focus on the process from the patients' perspective, to determine the desire for and acceptability of screening.