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,...
SUMMARYMicrovascular complications of insulin-dependent diabetes mellitus (IDDM) have been strongly associated with platelet abnormalities, whilst TNF-a has been implicated in the pathogenesis of this condition. However, at present it is not clear whether human circulating platelets express TNF-a or TNF receptors (TNF-R) or whether impaired expression of these molecules and of the TNF-reactive adhesion molecule ICAM-1 may be associated with platelet abnormalities in patients with IDDM. On this basis we investigated the platelet expression of these molecules in patients with IDDM complicated or uncomplicated by proliferative diabetic retinopathy (PDR) and in healthy subjects. We observed that the proportion of platelets staining for TNF-a was significantly higher in IDDM patients with active PDR than in patients without microvascular complications (P ¼ 0·0078), quiescent PDR (P ¼ 0·003) or healthy subjects (P ¼ 0·0013). Patients with active PDR also showed a higher proportion of platelets expressing TNF-RI (P ¼ 0·0052) and TNF-RII (P ¼ 0·015) than healthy controls or patients with quiescent PDR (P ¼ 0·009 and 0·0006, respectively). In addition, the percentage of ICAM-1 þ platelets was significantly higher in patients with active PDR than in patients with quiescent PDR (P ¼ 0·0065) or normal subjects (P ¼ 0·013). There was a direct correlation between platelet expression of TNF-a and that of TNF-R in PDR patients, indicating that platelet staining for TNF-a may be due to binding of this cytokine to its receptors. The results suggest that increased platelet expression of TNF-a, TNF-R and ICAM-1 in IDDM patients may constitute important markers of thrombocyte abnormalities during the development of microvascular complications of diabetes mellitus.
TNF-alpha has been implicated in the pathogenesis of insulin- dependent diabetes mellitus (IDDM). At present there are no studies linking serum levels of soluble TNF receptors (sTNF-R) to the development of diabetic microvascular complications such as proliferative diabetic retinopathy (PDR), or to the production of TNF-alpha in these patients. We investigated serum levels of sTNF receptors (sTNF-RI and sTNF-RII) in IDDM patients with or without PDR, and related these to the in vitro production of TNF-alpha upon activation of whole blood and isolated mononuclear cells (MNC). We observed higher serum levels of sTNF-RI in IDDM patients with active (range 945-6630 pg/ml; P = 0.029) or quiescent PDR (range 1675-4970 pg/ml; P = 0.00092) than in individuals with IDDM without retinopathy (range 657-2617 pg/ml) or healthy controls (range 710-1819 pg/ml; P = 0.0092 and 0.0023, respectively). Increased serum levels of sTNF-RII were also seen in IDDM patients with active PDR (range 1749-5218 pg/ml; P = 0.034) or quiescent PDR (range 1494-5249 pg/ml; P = 0.0084) when compared with disease controls (range 1259-4210 pg/ml) or healthy subjects (range 1237-4283 pg/ml). Whole blood production of biologically active TNF-alpha was lower in PDR patients than in disease (P = 0.04) and healthy controls (P < 0.005), contrasting with a higher production of TNF-alpha by lipopolysaccharide (LPS)-activated MNC from PDR patients (P = 0.013). Inhibition of TNF-alpha by TNF-R in plasma supernatants of activated blood from PDR patients was demonstrated by increase of TNF-alpha activity in the presence of anti-TNF-RI and anti-TNF-RII antibodies. These observations suggest that abnormalities in TNF-alpha production and control may operate during the development of microvascular complications of diabetes mellitus.
BackgroundThe establishment of minor eye conditions schemes (MECS) within community optometric practices provides a mechanism for the timely assessment of patients presenting with a range of acute eye conditions. This has the potential to reduce waiting times and avoid unnecessary referrals to hospital eye services (HES).ObjectiveTo evaluate the clinical effectiveness, impact on hospital attendances and patient satisfaction with a minor eye service provided by community optometrists.MethodsActivity and outcome data were collected for 12 months in the Lambeth and Lewisham MECS. A patient satisfaction questionnaire was given to patients at the end of their MECS appointment. A retrospective difference-in-differences analysis of hospital activity compared changes in the volume of referrals by general practitioners (GPs) from a period before (April 2011–March 2013) to after (April 2013–March 2015) the introduction of the scheme in Lambeth and Lewisham relative to a neighbouring area (Southwark) where the scheme had not been commissioned. Appropriateness of case management was assessed by consensus using clinical members of the research team.ResultsA total of 2123 patients accessed the scheme. Approximately two-thirds of patients (67.5%) were referred by their GP. The commonest reasons for patients attending for a MECS assessment were ‘red eye’ (36.7% of patients), ‘painful white eye’ (11.1%) and ‘flashes and floaters’ (10.2%). A total of 64.1% of patients were managed in optometric practice and 18.9% were referred to the HES; of these, 89.2% had been appropriately referred. First attendances to HES referred by GPs reduced by 26.8% (95% CI −40.5% to −13.1%) in Lambeth and Lewisham compared to Southwark.ConclusionsThe Lambeth and Lewisham MECS demonstrates clinical effectiveness, reduction in hospital attendances and high patient satisfaction and represents a successful collaboration between commissioners, local HES units and primary healthcare providers.
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