Barriers to integrating routine depression screening into community low vision rehabilitation services: a mixed methods study

Developing interventions to improve detection of depression in primary healthcare settings in rural Ethiopia

BACKGROUND

The poor detection of depression in primary healthcare (PHC) in low- and middle-income countries continues to threaten the plan to scale up mental healthcare coverage.

AIMS

To describe the process followed to develop an intervention package to improve detection of depression in PHC settings in rural Ethiopia.

METHOD

The study was conducted in Sodo, a rural district in south Ethiopia. The Medical Research Council's framework for the development of complex interventions was followed. Qualitative interviews, observations of provider-patient communication, intervention development workshops and pre-testing of the screening component of the intervention were conducted to develop the intervention.

RESULTS

A multicomponent intervention package was developed, which included (a) manual-based training of PHC workers for 10 days, adapted from the World Health Organization's Mental Health Gap Action Programme Intervention Guide, with emphasis on depression, locally identified depressive symptoms, communication skills, training by people with lived experience and active learning methods; (b) screening for culturally salient manifestations of depression, using a four-item tool; (c) raising awareness among people attending out-patient clinics about depression, using information leaflets and health education; and (d) system-level interventions, such as supportive supervision, use of posters at health facilities and a decision support mobile app.

CONCLUSIONS

This contextualised, multicomponent intervention package may lead to meaningful impact on the detection of depression in PHC in rural Ethiopia and similar settings. The intervention will be pilot tested for feasibility, acceptability and effectiveness before its wider implementation.

Discussing depression in patients with visual impairment differs across countries: Validation of a prediction model in healthcare providers

PURPOSE

Healthcare providers often experience difficulties in discussing depression with adults with visual impairment (VI), obstructing timely referral. The purpose of this study was to examine predictors of routine discussions of depression with adults with VI from the perspective of different healthcare providers from different countries.

METHODS

Cross-sectional survey data from Welsh (N = 122), Australian (N = 94) and Dutch (N = 100) healthcare providers, that is eye care practitioners (ECPs) and low-vision care providers (LVCPs), were analysed. Multivariable logistic regression analysis was performed in the Welsh sample to determine predictors for discussing depression. Internal validation was conducted by using a bootstrap method, and the recalibrated model was externally validated in the Australian and Dutch sample.

RESULTS

Work experience in eye care services (OR 0.95; 95% confidence interval (CI) 0.92 to 0.99) and perceived barriers (OR 0.95; 95% CI 0.92 to 0.98) was found to predict discussing depression with patients. The area under the curve (AUC) of 0.73 reflected good discrimination of the model. The model showed a slightly better fit in the Australian sample (AUC = 0.77), but a poor fit in the Dutch sample.

CONCLUSION

The final prediction model was not generalizable to Dutch healthcare providers. They perceived less barriers in depression management than Welsh and Australian healthcare providers. This could be explained by differences in ECPs and LVCPs roles and responsibilities, increased attention on mental health and differences in organizing health care. Differences between healthcare providers' responsibilities and support needs should be taken into account while creating a facilitating environment to discuss depression.

Community pharmacists' acceptability of pharmacist-delivered depression screening for older adults: a qualitative study

BACKGROUND

Late-life depression often goes underdiagnosed and undertreated, affecting the quality of life of older adults. Pharmacists are well-placed to identify older adults who may be at risk of depression by using appropriate screening tools.

AIM

To explore community pharmacists' acceptability of performing late-life depression screening in Australian community pharmacies.

METHOD

Semi-structured interviews with community pharmacists were conducted to gauge their perceptions regarding delivering depression screening services for older adults. Data analysis was conducted using an iterative, inductive approach. Key themes were identified, which were further explored and divided into subthemes. Subthemes were categorised as either barriers or facilitators. Each subtheme was mapped to the Capability, Opportunity, Motivation-Behaviour model by classifying whether they impacted pharmacists' capability, opportunity, or motivation regarding depression screening.

RESULTS

Fifteen pharmacists were interviewed, 12 of whom were female and 11 of whom practised in a metropolitan area. Four key themes were identified including: training needs, environmental factors, pharmacists' roles, and organisational support, which were further divided into 13 subthemes. Three subthemes were mapped to Capability, seven to Opportunity and three to Motivation. Barriers included lack of resources and lack of remuneration, while facilitators included training, pharmacists' accessibility, and rapport with consumers.

CONCLUSION

The findings of this study demonstrate that while community pharmacists found depression screening for older adults in community pharmacies to be an acceptable service, there remains a need for the development of funding schemes and standardised guidelines for pharmacist-delivered depression screening for older adults.

The use of augmented reality and virtual reality for visual field expansion and visual acuity improvement in low vision rehabilitation: a systematic review

INTRODUCTION

Developments in image processing techniques and display technology have led to the emergence of augmented reality (AR) and virtual reality (VR)-based low vision devices (LVDs). However, their promise and limitations in low vision rehabilitation are poorly understood. The objective of this systematic review is to appraise the application of AR/VR LVDs aimed at visual field expansion and visual acuity improvement in low vision rehabilitation.

METHODS

A systematic search of the literature was performed using MEDLINE, Embase, PsychInfo, HealthStar, and National Library of Medicine (PubMed) from inception to March 6, 2022. Articles were eligible if they included an AR or VR LVD tested on a sample of individuals with low vision and provided visual outcomes such as visual acuity, visual fields, and object recognition.

RESULTS

Of the 652 articles identified, 16 studies comprising 382 individuals with a mean age of 52.17 (SD = 18.30) years, and with heterogeneous low vision etiologies (i.e., glaucoma, age-related macular degeneration, retinitis pigmentosa) were included in this systematic review. Most articles used AR (53%), VR (40%), and one article used both AR and VR. The main visual outcomes evaluated were visual fields (67%), visual acuity (65%), and contrast sensitivity (27%). Various visual enhancement techniques were employed including variable magnification using digital zoom (67%), contrast enhancements (53%), and minification (27%). AR LVDs were reported to expand the visual field from threefold to ninefold. On average, individuals using AR/VR LVDs experienced an improved in visual acuity from 0.9 to 0.2 logMAR. Ten articles were classified as high or moderate risk of bias.

CONCLUSION

AR/VR LVDs were found to afford visual field expansion and visual acuity improvement in low vision populations. Even though the results of this review are promising, the lack of controlled studies with well-defined populations, use of small, convenience samples, and incomplete reporting of inclusion and exclusion criteria among included studies makes it challenging to judge the true impact of these devices. Future studies should address these limitations and compare various AR/LVDs to determine what is the ideal LVD type and vision enhancement combination based on the user's level of visual ability and lifestyle.

Systematic screening for anxiety and depression in cardiac rehabilitation - are we there yet?

BACKGROUND

Anxiety and depression are prevalent in 20% of patients with acute coronary syndrome (ACS) and associated with poor outcomes. Guidelines recommend screening for these conditions in cardiac rehabilitation (CR) however, clinical practice is inconsistent. Sparse knowledge exists on determinants for screening.

METHODS

This observational study used data from the National Audit of Cardiac Rehabilitation from January 2016-December 2019. A multivariate logistic regression model was performed to analyze patient- and provider level determinants for screening for anxiety and depression among patients with ACS.

RESULTS

The population consisted of 138,018 patients, where 82,507 (59.8%) were screened and 55,511 (40.2%) were not. Younger age, non-white ethnicity, living in areas of social deprivation, current smoking, body mass index>30, and physical activity<150 min per week were negatively correlated with patients being screened. Compared to patients having a percutaneous coronary intervention, patients undergoing coronary artery bypass grafting or medical treatment were less likely to be screened. History of anxiety, depression, osteoporosis, chronic back problems, and asthma were positively correlated with screening, while chronic obstructive pulmonary disease, diabetes, hypertension, and stroke were negatively correlated with screening. Regarding provider level, certification of CR centers was positively associated with screening, while looking over time data showed an incremental negative trend in screening from 2016 to 2019.

CONCLUSION

We found both patient and provider level determinants of screening for anxiety and depression. Clinical practice is still inconsistent especially for high-risk groups. We recommend systematic screening to enable tailored interventions which in turn may mitigate inequity in health outcomes.

Perspectives on Implementing the Patient Health Questionnaire-4 in Low-Vision Service Organizations to Screen for Depression and Anxiety

Purpose

To describe the process of implementing a screening questionnaire for depression and anxiety, the Patient Health Questionnaire-4 (PHQ-4), in low-vision service (LVS) organizations.

Methods

This study consisted of three parts: (1) a usability study combined with semistructured interviews, in which clients (n = 10) of LVS organizations expressed their preference for using the PHQ-4; (2) a feasibility study, in which the PHQ-4 was implemented on a small scale and its use was evaluated, involving health care providers (n = 6) and clients (n = 9); and (3) semistructured interviews to identify barriers and facilitators for implementing the PHQ-4 according to health care providers (n = 6) and managers (n = 4) of LVS organizations. Results were integrated into themes and linked to constructs of the Consolidated Framework for Implementation Research (CFIR).

Results

Six themes were derived from the substudies: (1) quality of the intervention, (2) applicability for clients of LVS organizations, (3) attitude and needs of clients, (4) attitude of health care providers, (5) support within LVS organizations, and (6) embedment in current practice. Results could be linked to 12 CFIR constructs. The constructs "relative advantage," "patient needs and resources," and "available resources" emerged most prominently in our themes as either barrier or facilitator.

Conclusions

The PHQ-4 seems an appropriate screening instrument for use in LVS organizations because of its quality and adaptable use. It might provide opportunities to timely detect depression and anxiety, but challenges in implementing the PHQ-4 should be considered.

Translational Relevance

Barriers and facilitators for implementing the PHQ-4 may also apply to implementing other questionnaires in LVS organizations.

Association Between Visual Impairment and Depression in Patients Attending Eye Clinics: A Meta-analysis

IMPORTANCE

Given that depression is treatable and some ocular diseases that cause visual loss are reversible, early identification and treatment of patients with visual impairment who are most at risk of depression may have an important influence on the well-being of these patients.

OBJECTIVE

To conduct a meta-analysis on the prevalence of depression in patients with visual impairment who regularly visit eye clinics and low vision rehabilitation services.

DATA SOURCES

MEDLINE (inception to June 7, 2020) and Embase (inception to June 7, 2020) were searched.

STUDY SELECTION

Studies that obtained data on the association between acquired visual impairment and depression among individuals aged 18 years or older were identified and included in this review. Exclusion criteria comprised inherited or congenital eye diseases, review studies, unpublished articles, abstracts, theses, dissertations, and book chapters. Four independent reviewers analyzed the results of the search and performed the selection and data extraction to ensure accuracy.

DATA EXTRACTION AND SYNTHESIS

Meta-analyses of prevalence were conducted using random-intercept logistic regression models. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

MAIN OUTCOMES AND MEASURES

Proportion of depression.

RESULTS

A total of 27 studies were included in this review, and all but 2 included patients older than 65 years. Among 6992 total patients (mean [SD] age, 76 [13.9] years; 4195 women [60%]) with visual impairment, in 1687 patients with depression, the median proportion of depression was 0.30 (range, 0.03-0.54). The random-effects pooled estimate was 0.25 (95% CI, 0.19-0.33) with high heterogeneity (95% predictive interval, 0.05-0.70). No patient characteristic, measured at the study level, influenced the prevalence of depression, except for the inclusion of patients with cognitive impairment (0.33; 95% CI, 0.28-0.38 in 14 studies vs 0.18; 95% CI, 0.11-0.30 in 13 studies that excluded this with major comorbidities; P = .008). The prevalence of depression was high both in clinic-based studies (in 6 studies, 0.34; 95% CI, 0.23-0.47) and in rehabilitation services (in 18 studies, 0.25; 95% CI, 0.18-0.33 vs other settings in 3 studies, 0.15; 95% CI, 0.05-0.38; P = .17), and did not vary by visual impairment severity of mild (in 8 studies, 0.24; 95% CI, 0.14-0.38), moderate (in 10 studies, 0.29; 95% CI, 0.21-0.39), and severe (in 5 studies, 0.29; 95% CI, 0.12-0.56; P = .51).

CONCLUSIONS AND RELEVANCE

The results of this meta-analysis suggest that depression in patients with visual impairment is a common problem that should be recognized and addressed by the health care professionals treating these patients.

Training results in increased practitioner confidence and identification of depression in people with low vision: a mixed methods study

PURPOSE

The prevalence of depression in people with low vision is high and often goes undiagnosed. There is the potential for those who provide low vision services to perform concurrent depression screening. However, prior training in depression identification and suitable referral pathways is required. The aims of this study were: (1) to assess the impact of a training programme on practitioners' confidence and behaviour in addressing depression in patients with low vision, and (2) to review the training programme and identify areas for further development.

METHODS

A convergent mixed methods approach was used. Questionnaires were completed by practitioners pre-, immediately post- and 6 months post- training (n = 40) to assess practitioner confidence in approaching depression in patients with low vision. Qualitative interviews were performed with a subset of practitioners 6 months post-training (n = 9). Additionally, routine data from the Low Vision Service Wales (LVSW) database was used to determine the change in the number of practitioners identifying depression in patients, and the change in the number of patients identified at risk of depression 6 months post-training.

RESULTS

Of the 148 practitioners who completed low vision assessments pre- and post-training, 28 (18.9%) documented risk of depression in their patients pre-training, which increased substantially to 65 (43.9%) post-training (p < 0.0001). Mixed methods analysis confirmed increased documentation of depressive symptoms by practitioners. Practitioner confidence increased following training, with 92.3% feeling more confident to approach emotional issues with patients and 92.2% intending to use the recommended screening tool to identify depression. Interviews provided insight into areas where confidence was still lacking. Quantitative questionnaires revealed that training content was considered appropriate by 91% of participants. Interviews confirmed these findings while expanding upon possibilities for programme improvement.

CONCLUSIONS

Training for depression screening was found to be time-efficient and acceptable for LVSW practitioners and shown to increase practitioner confidence in the identification of depression. Additionally, the programme changed behaviour, resulting in an increase in the identification of depression in patients with low vision. However, this is a complex topic and ongoing development is required to embed depression screening as an integral part of low vision services.