Detection of depression_in_patients_with_low.4

ORIGINAL ARTICLE
Detection of Depression in Patients with Low Vision
Gwyneth Rees*, Eva K. Fenwick†
, Jill E. Keeffe*, David Mellor*, and Ecosse L. Lamoureux*
ABSTRACT
Purpose. Depression is common in people with vision impairment and further reduces levels of functioning independent
of vision loss. However, depression most often remains undetected and untreated this group. Eye health professionals
(EHPs) (ophthalmic nurses, ophthalmologists, optometrists, and orthoptists) and rehabilitation workers (RWs) may be able
to play a role in detecting depression. This study aimed to identify current practice and investigate factors associated with
depression management strategies.
Methods. A self-administered cross-sectional survey of EHPs and RWs assessed current practice including confidence in
working with depressed people with vision impairment; barriers to recognition, assessment, and management of depression;
beliefs about the consequences, duration, and efficacy of treatment for depression in individuals with vision impariment.
Results. Ninety-four participants aged 23 to 69 years took part. Thirty-seven participants (39.8%) stated that they
attempted to identify depression as part of patient management, with RWs significantly more likely to do so (n ϭ 17,
60.7%) than EHPs (n ϭ 20, 30.8%; p ϭ 0.007). Intention to identify depression was not associated with sociodemo-
graphic factors, professional experience in eye care services, or the length and number of patient consultations, but a
significant relationship was found for confidence, barriers, and beliefs about depression (p Ͻ 0.05). No consistent
depression management strategy emerged and a range of barriers were highlighted.
Conclusions. Training programs are needed to provide EHPs and RWs with the skills and resources to address depression
in people with vision loss under their care and to support the development of procedures by which concerns about
depression can be identified objectively, documented, and included as part of a referral to appropriate services.
(Optom Vis Sci 2009;86:1328–1336)
Key Words: depression, professional development, barriers, training needs
T
he emotional consequences of vision loss have been well
described, with rates of depression estimated to be 2 to 5
times greater in older adults with low vision than in sighted
individuals of similar age.1–5
Depression has been shown to exac-
erbate disability and further reduce levels of functioning in this
group independent of vision loss, by reducing motivation, initia-
tive, and resiliency.6,7
Even minimal depressive symptoms, which
do not meet the diagnostic criteria, are associated with functional
decline not accounted for by eye disease or other medical prob-
lems.8
The diagnostic criteria for depression are well established,
and good screening tools exist. Effective medicinal and therapeutic
regimes are also available to treat depression, and treatment is
most effective when implemented early. Despite this, depres-
sion often remains undetected and therefore untreated in peo-
ple with vision loss.6,9,10
General practitioners (GPs) play a central role in detecting and
managing depression in primary care settings. However, research
has identified a range of patient, doctor, and practice factors that
present barriers to detection and management of depression in
primary care.11–13
The most prominent ones include practitioners’
attitudes to depression, low confidence in assessing depression, and
insufficient access to mental health resources.11–13
Communica-
tion problems may make depression even more difficult to detect
in older adults compared with younger adults. Specifically, GPs are
less likely to ask older adults about their psychological and social
wellbeing, and older adults are less likely to raise these issues.14
Vision impairment is yet another barrier to effective doctor–patient
communication.15
Indeed, patients with vision impairment and
depression have been identified as a group in which depression is
least likely to be recognized by their GP.16
Eye health professionals (EHPs), including ophthalmic nurses,
ophthalmologists, optometrists, orthoptists, and rehabilitation work-
ers (RWs), are key care providers for people with vision impairment
who could play a role in detecting depression. In the recently pub-
lished clinical guidelines for managing depression, the National Insti-
*PhD
†
MSc
Centre for Eye Research Australia, the Royal Victorian Eye and Ear Hospital, Uni-
versity of Melbourne, Department of Opthalmology (GR, EKF, JEK, ELL), and
School of Psychology, Deakin University (DM), Melbourne, Victoria, Australia.
1040-5488/09/8612-1328/0 VOL. 86, NO. 12, PP. 1328–1336
OPTOMETRY AND VISION SCIENCE
Copyright © 2009 American Academy of Optometry
Optometry and Vision Science, Vol. 86, No. 12, December 2009

tute of Clinical Excellence recommended that screening should take
place in primary care and general hospitals for those at high risk of
depression, including patients with an illness causing disability.17
Studies from other primary and tertiary health care fields, including
oncology, heart disease, diabetes, maternal health, and stroke, have
described the processes by which depression is managed in these set-
tings and barriers to care.18–24
However, no quantitative study to date
has focused on care providers for people with vision impairment, and
itisunclearhowEHPsorRWsrecognizeandrespondtodepressionin
their patients. In addition, EHPs and RWs are diverse groups with
different professional backgrounds and work settings, and they may
also have access to different resources, hold different views, and expe-
rience different barriers.
This study therefore aimed to identify current practice of eye
care professionals and to investigate factors associated with their
responses to depression. We also investigated the barriers experi-
enced by the different professional groups, and their training
preferences to determine how best to support practitioners in
identifying and responding to depression.
METHODS
Participants and Recruitment
The study was a cross-sectional survey of EHPs and RWs across
the Australian state of Victoria. Ethical approval was received from
the Human Research and Ethics Committee of the Royal Victo-
rian Eye and Ear Hospital, and all participants gave signed consent.
Following consultations on appropriate recruitment strategies,
questionnaires were distributed to EHPs through their profes-
sional organizations and to RWs through their rehabilitation
agencies. Four weeks after the initial questionnaire distribution,
reminder packs were sent out to nonresponders.
Measures
Background
Sociodemographics and details of professional background,
training, and current work were recorded in the first section of the
questionnaire.
Current Practice
Participants were asked to outline the current resources available
to manage depression and to rate the likelihood of undertaking
nine actions if they suspect a patient to be depressed (e.g., “Provide
education and information about depression”) using a 4-point
scale (“definitely unlikely” to “definitely likely”).
Confidence in Recognizing and Responding to Depression
in People with Vision Impairment
Adapted from an existing measure to assess confidence in work-
ing with elderly people with depression.25
Participants respond to
14 items on a 4-point scale (“not confident” to “very confident”).
Summed scores range from 14 to 56 with high scores representing
greater confidence in working with depressed patients.
Barriers to Recognition, Assessment,
and Management of Depression
Adapted from an existing measure to assess barriers to work-
ing with depressed elderly patients.25
The scale includes 13
items, which are rated on a 4-point scale (“strongly disagree” to
“strongly agree”). Summed scores range from 13 to 52 with
high scores representing greater barriers to working with pa-
tients with depression.
Training Needs and Future Practice
A 10 item study-specific measure to assess (i) interest in
improving knowledge (signs and symptoms of depression and
services and resources available), (ii) use of tools (guidelines and
screening tools), (iii) interest in developing skills (communica-
tion skills and identifying depression), and (iv) interest in be-
havior change (attendance at professional development, discuss
emotional issues, refer patients, and educate patients). Partici-
pants rate each item on a 4-point scale (“strongly disagree” to
“strongly agree”).
Beliefs about Depression in Individuals with
Vision Impairment
Beliefs about depression in individuals with vision impari-
ment were assessed using an adaptation of the Illness Percep-
tions Questionnaire (Revised).26
Beliefs about the conse-
quences (six items) (e.g., “depression is a serious condition for a
person with vision impariment”), timeline (six items) (e.g., “de-
pression will last a long time for a person with vision impair-
ment”), and efficacy of treatment for depression (five items)
(e.g., “treatment can control depression in a person with vision
impairment”) were assessed using a 5-point scale (“strongly
disagree” to “strongly agree”). Scores ranged from 5 to 30 for
consequences and timeline and 2 to 25 for treatment control.
High scores represent beliefs that depression is serious, long-
lasting condition and that treatment is effective.
Analysis
Descriptive statistics were used to describe current practice and
barriers reported. Univariate analysis using t tests, analysis of variance,
andcorrelationsdeterminedfactorsassociatedwithcurrentdepression
management strategies. Analysis of variance and post hoc tests were
used to identify differences between professional groups.
RESULTS
Response Rates
Six hundred sixty-six questionnaires were sent out to optome-
trists (n ϭ 82), ophthalmic nurses (n ϭ 97), orthoptists (n ϭ 205),
ophthalmologists (n ϭ 189), and RWs (n ϭ 93). A total of 94
questionnaires were returned, giving a final response rate of 14.1%.
Responses rates were significantly higher for RWs (n ϭ 28, 30.1%)
than the EHPs: optometrists (n ϭ 12, 14.6%); ophthalmic nurses
(n ϭ 12, 12.4%); orthoptists (n ϭ 22, 10.7%); ophthalmologists
(n ϭ 20, 10.6%) [␹2
ϭ 24.33, degrees of freedom (df) ϭ 4, p Ͻ
Depression in Patients with Low Vision—Rees et al. 1329

0.001]. Reminders had a substantial impact on the overall re-
sponse rate, with 34.0% of questionnaire returns coming after
the reminder.
Participants
Tables 1 and 2 describe the participants. The sample was largely
female aged between 23 and 69 years. The length of time the
participants had been in their current role, or eye care services in
general, ranged from less than a year to more than 35 years. Work
settings included public hospital, private practice, community set-
tings, or combinations of these and varied across professional
groups. The number of patients with vision impairment seen each
week ranged from 1 to 120, and the time spent with each patient
also varied considerably (1 to 200 min). Professional groups dif-
fered on the number of people with vision impairment reported to
be seen each week (F4,87 ϭ 7.612, p Ͻ 0.001) and the amount of
time spent with each patient (F4,87 ϭ 43.239, p Ͻ 0.001). Oph-
thalmic nurses and ophthalmologists saw significantly more pa-
tients with vision impairment than did optometrists or RWs (p Ͻ
0.05). However, RWs had significantly longer consultations with
patients than any other group (p Ͻ 0.001), and optometrists had
significantly longer consultations than ophthalmologists (p ϭ
0.005). Less than 20% (n ϭ 18) of participants reported having
ever received any training in depression. Although few participants
(n ϭ 15, 16%) reported having personally experienced depression,
more than 70% reported knowing family or friends who had.
Current Practice
Identification of Depression
Overall, 39.8% (n ϭ 37) of participants stated that they at-
tempted to identify depression as part of patient management,
with RWs significantly more likely to do so (n ϭ 17, 60.7%) than
EHPs (n ϭ 20 30.8%) (␹2
ϭ 7.325, df ϭ 1, p ϭ 0.007). Socio-
demographic and work-related factors including duration in eye
care services and consultation times were not associated with in-
tention to identify depression, but confidence, barriers, and beliefs
about depression were associated (p Ͻ 0.05). Compared with those
who did not attempt to detect depression, participants who aimed
to identify depression were more confident (mean ϭ 37.89, SD
7.11 vs. mean ϭ 30.12, SD 7.66; t ϭ 4.772, df ϭ 85, p Ͻ 0.001),
reported fewer barriers (mean ϭ 27.09, SD 7.47 vs. mean ϭ
33.63, SD ϭ 7.05; t ϭ Ϫ4.034, df ϭ 80, p Ͻ 0.001), and believed
depression to hold greater consequences for a person with vision
impairment (mean ϭ 26.20, SD 2.92 vs. mean ϭ 24.59, SD 3.07;
t ϭ 2.48, df ϭ 89, p ϭ 0.015).
Management of Patients Who may be Depressed
The resources available to support patient management varied
according to work setting. The majority of participants working in
public hospitals stated that they had access to a social worker (n ϭ
29, 76.3%), RWs had access to a psychologist (n ϭ 18, 60%) and
counselor (n ϭ 16, 53.3%), and were more likely to refer to these
services than EHPs (␹2
ϭ 34.813, df ϭ 4, p Ͻ 0.000). Resources
available in private practice were limited, with more than a third
(n ϭ 16, 38.1%) of participants working in this setting reporting
no onsite resources. Ophthalmologists were most likely to report
TABLE 1.
Sociodemographic, work, and personal characteristics of
the 94 participants
Age (yr)
Mean 42.1
Range 23.3–69.4
Sex, n (%)
Female 71 (75.5)
Male 23 (24.5)
Time in current role (yr)
Mean 8.5
Range 0.4–37
Time in eye care services (yr)
Mean 14.6
Range 0.4–42
Previous depression training, n (%)
Yes 18 (19.1)
No 76 (80.9)
Personal experience of depression,a
n (%)
Yes 15 (16.0)
No 65 (69.1)
Family or friends’ experience of depression,a
n (%)
Yes 66 (70.2)
No 27 (28.7)
a
Percentage does not total 100 due to missing data.
TABLE 2.
Work setting and number and duration of consultations with patients with vision impairment for each professional group
Professional group Most common work setting
No. patients with vision
impairment seen each
week, mean (SD)
Average time spent
with each patient
(min), mean (SD)
Ophthalmic nurse (n ϭ 12) Public hospital (n ϭ 11, 91.7%) 29.7 (32.3) 20.5 (34.05)
Optometrist (n ϭ 12) Private practice (n ϭ 7, 58.3%) 5.08 (8.9) 46.4 (15.6)
Ophthalmologist (consultant)
(n ϭ 20)
Combination of private practice and
public hospital (n ϭ 13, 65%)
37.9 (33.8) 13.0 (3.6)
Orthoptist (n ϭ 22) Private practice (n ϭ 8, 36.4%) 20.2 (17.7) 23.6 (26.7)
Rehabilitation worker (n ϭ 28) Rehabilitation agency (n ϭ 27, 96.7%) 8.3 (4.3) 98.2 (32.6)
1330 Depression in Patients with Low Vision—Rees et al.

that they had access to a psychiatrist both in public setting (n ϭ 8,
53.3%) and private practice (n ϭ 7, 38.9%).
Table 3 outlines the depression management strategies and
factors associated with each strategy. The most common actions
were referral to a GP (n ϭ 75, 79.8%) and referral to rehabilitation
services (n ϭ 71, 75.5%). Only a quarter (24.5%) stated that they
were likely to provide information and education about depression.
Level of confidence in managing depressed patients and barriers to
management were consistently significantly associated with a range of
actions (p Ͻ 0.05). In addition, participants’ beliefs about depression
were also associated with specific actions. For example, those with
greater belief in the effectiveness of treatment for depression in pa-
TABLE 3.
Depression management strategies and associated sociodemographic, work, and psychosocial characteristics
Depression
management
strategies
Total % of
participants
likely to use this
strategy (n ϭ 94)
Factors positively
associated with strategy
Factors negatively
associated with strategy Professional group differences
GP referral 79.8 — — 1 Ophthalmologist compared
to RWa
(F4,88 ϭ 2.756a
)
Vision rehabilitation
referral
75.5 — — —
Discussion of
feelings
74.5 Confidence (r ϭ 0.589,b
n ϭ 86) and beliefs
about consequences
(r ϭ 0.340,b
n ϭ 91)
Barriers (r ϭ Ϫ0.525,b
n ϭ 81)
No. VIP per wk
(r ϭ Ϫ0.225,a
n ϭ 92)
Duration in current
position (r ϭ Ϫ0.210,a
n ϭ 92)
—
Referral to a
self-help or
support group
50.0 Confidence (r ϭ 0.330,c
n ϭ 86) and depression
training (yes) (t ϭ
3.588,b
df ϭ 91)
Barriers (r ϭ Ϫ0.245,a
n ϭ 81)
1 RW compared with
orthoptista
(F4,88 ϭ 2.970a
)
Referral to a mental
health service
such as
counseling or a
psychologist
35.1 Time per VIP (r ϭ 0.428,b
n ϭ 89)
Confidence (r ϭ 0.317,c
n ϭ 84)
Beliefs about treatment
(r ϭ 0.267,a
n ϭ 90)
Depression training (yes)
(t ϭ 2.784,c
df ϭ 89)
n ϭ 79)
No. VIP per week
(r ϭ Ϫ0.221,a
n ϭ 89)
1 RW compared with
ophthalmic nurse,b
ophthalmologist,b
optometrist,b
or orthoptistb
(F4,86 ϭ 12.668b
)
Referral to another
health
professional
35.1 Confidence (r ϭ 0.255,a
n ϭ 78)
Beliefs about treatment
(r ϭ 0.237,a
n ϭ 82)
— 1 Ophthalmic nurses
compared with
ophthalmologistsc
or
orthoptista
(F4,78 ϭ 4.190c
)
Provide information
and education
about depression
24.5 Confidence (r ϭ 0.417,b
n ϭ 86)
Depression training (yes)
(t ϭ 2.878,c
df 91)
n ϭ 81)
No significant post hoc test
results (F4,88 ϭ 2.914a
)
Avoid discussing
patients’ feelings
14.9 Barriers (r ϭ 0.430,b
n ϭ 80)
Time in current position
(r ϭ Ϫ0.265,a
n ϭ 91)
Confidence (r ϭ Ϫ0.535,b
n ϭ 85)
Beliefs about consequences
(r ϭ Ϫ0.335,b
n ϭ 90)
—
Use a depression
screening
questionnaire
4.3 Beliefs about treatment
(r ϭ 0.219,a
n ϭ 91).
Barriers (r ϭ Ϫ0.275,a
n ϭ 80)
—
Confidence (r ϭ 0.217,a
n ϭ 85)
The following Likert scale was used: 1, “definitely unlikely”; 2, “probably unlikely”; 3, “probably likely”; 4, “efinitely likely.” Post
hoc comparisons for professional group differences were computed using Tukey’s honestly significant difference (HSD) test.
Significant correlations or group differences are noted using a
p Յ 0.05, b
p Յ 0.001, and c
p Յ 0.01.

tients with vision impairment were more likely to refer to a
mental health service (p ϭ 0.011) or other health professionals
(p ϭ 0.032) and use a depression screening tool (p ϭ 0.037).
Few work-related factors were associated with referral strategies,
except referral to a mental health service was positively associated with
consultation time (p Ͻ 0.001), and negatively associated with the
number of patients seen each week (p ϭ 0.046). Talking to patients
about their feelings was negatively associated with the number of pa-
tients seen each week (p ϭ 0.031) and duration in current role (p ϭ
0.044). Those participants who had received some form of training in
depression previously were more likely to use a range of strategies
including referral to self-help/support group, mental health service,
and providing information and education (all p Ͻ 0.05).
Barriers to Patient Management
Table 4 outlines the barriers to recognizing and responding to
depression reported by participants. Common barriers included
absence of standard procedures to follow (n ϭ 64, 68.1%); limited
knowledge about depression (n ϭ 63, 67%); and lack of training in
depression (n ϭ 59, 62.8%). Time and workload were found to be
a greater barrier for ophthalmic nurses, ophthalmologists, and or-
thoptists than RWs (all p values Յ0.002). For ophthalmologists
and orthoptists, the focus of their role on eye health was a greater
barrier than for RWs (all p values Ͻ0.05). Knowledge about what to
do when a patient may be depressed was a greater barrier for orthop-
tists compared with RWs (p ϭ 0.007). Ophthalmic nurses reported
that the environment in which they work was a greater barrier to
holding private discussions with patients compared with all other
groups (all p values Ͻ0.05), and their lack of ongoing contact with
patients was a greater barrier compared with RWs (p Ͻ0.001), or-
thoptists, or ophthalmologists (all p values Ͻ0.05).
Training Needs and Future Preferences
The majority of participants were enthusiastic about training
opportunities (Table 5). More than 90% of participants like to be
able to refer patients to appropriate services and improve their
knowledge of services and treatment options. More than 80% of
participants indicated that they would like to have more informa-
tion about signs and symptoms of depression, to be able to identify
depression more easily, and to enhance their communication skills.
Compared with all other groups, ophthalmologists were least likely
towanttoattendaprofessionaldevelopmenteventtoimproveknowl-
edge or skills for managing patients with depression (p Ͻ 0.05). Op-
tometrists had a stronger preference for information about the signs
and symptoms of depression than ophthalmologists or RWs (p Ͻ
0.05). Ophthalmic nurses were more keen to discuss patients’ feelings
than ophthalmologists or RWs (p Ͻ 0.001) and to use a depression
screeningtoolthanophthalmologists,orthoptists,orRWs(pϽ0.05).
DISCUSSION
Despite the high prevalence of depression in people with vision
impairment, little is known about how professionals working with
this patient group manage depression. In this study, we highlight
that active identification of depression is not a routine part of
patient care for EHPs, although it occurs to some extent in reha-
bilitation settings. Work-related factors, such as number of pa-
tients seen per week or consultation duration, were not related to
an interest in or intention to screen patients for depression. In-
stead, participants’ confidence, barriers, and beliefs about the con-
sequences of depression and treatment efficacy were significantly
associated with likelihood of identifying and responding to depres-
sion. This is promising because work factors may not be easily
amenable to change, whereas level of confidence and beliefs can be
effectively targeted by training programs.27–30
Our data indicate that if participants suspect depression in their
patients, they respond with a variety of strategies, although they are
often limited by resources available to them, particularly EHPs
working in private settings. Referrals to a GP or vision rehabilita-
tion service were most common and seemed to be used often by all
groups. Both pathways hold promise. In Australia, GPs have access
to Medicare-funded psychological services for depression. Vision
rehabilitation services can also include counseling services, and our
results also suggest that RWs may have more time and capacity
within their role to focus on emotional health. However, there are
two major caveats in these pathways. First, it is unclear whether
patients will use the referral. A recent study of a rehabilitation
service link to a public eye hospital in Victoria, Australia, found
that less than half of those referred attended.31
Patients with de-
pressive symptoms are even less likely to follow such a referral
through, and, if they do, research has found that they use fewer
rehabilitation services.9
Therefore, it has been suggested that it is
necessary to treat depression in people with vision impairment
before rehabilitation to improve rehabilitation outcomes.6,32–34
Second, it is unclear whether concerns about depression are dis-
cussed with the patient or if these concerns are noted as part of the
referral. Our data suggest that it is unlikely that depression is ex-
plicitly discussed with the patient. We did not ask in this survey
whether participants provided information about their concerns to
the patient as part of the referral process, although findings from
our focus groups with EHPs suggest that there are no standard
systems in place to support this.35
Given the difficulties in identi-
fying depression in primary care settings already described, it is
likely that depression may remain undetected whether the GP or
rehabilitation agencies are not made aware of the concerns of the
EHPs. There is a clear opportunity to build on these existing re-
ferral strategies by developing procedures by which concerns about
depression can be identified objectively, documented, and included as
part of the referral and providing resources and skills for EHPs and
RWs to address the issue of depression with their patients.
It is promising to see that previous training in depression is
related to increased likelihood of responding to depression and that
participants are enthusiastic about future training opportunities.
Participants expressed a strong desire to increase their knowledge
of services, treatment options, and referral strategies. This infor-
mation should be provided as clear guidelines or procedures suit-
able to particular settings. Indeed, training programs should be
developed to suit the needs and preferences of different groups.
Our results indicate that time and workload issues were most prob-
lematic for ophthalmic nurses, ophthalmologists, and orthoptists,
who would need quicker strategies suited to the context in which
they work. For ophthalmic nurses, in particular, it is important to
ensure that strategies are not dependent on ongoing contact and
are easily administered in a busy hospital setting. Ophthalmolo-

gists were least likely to be interested in training, possibly because
of existing knowledge from medical training. However, their sup-
port is likely to be critical in the development and implementation
of local guidelines and procedures.
Currently, Ͻ5% of participants reported to use a screening tool
withpatientstheysuspectedtobedepressedalthoughmorethan50%,
notably ophthalmic nurses, indicated a desire to do so. A range of
screening tools for depression exists and short two-item tools, which
havebeenshowntobevalid,36,37
maybeusefulinbusysettings.These
tools will be valuable in assisting EHPs and RWs to identify those
patients who may benefit further from a more detailed assessment and
in providing information to support this referral.
TABLE 4.
Barriers to depression management reported by each professional group
Barriers to working with
patients with vision
impairment
and depression
Total % of
participants who
agreed this was a
barrier (n ϭ 94)
Mean (SD)
ON OPH OPT ORT RW
Absence of standard
proceduresa
68.1 3.33 (0.65) 2.75 (0.97) 3.00 (0.74) 3.15 (0.93) 2.39 (0.92) F4,87 ϭ 3.508,
p ϭ 0.011
Limited knowledge of
depressiona
67.0 2.92 (0.90) 2.90 (0.72) 2.75 (0.75) 3.05 (0.81) 2.39 (0.79) F4,88 ϭ 2.498,
p ϭ 0.048
Lack of training to know
if a patient might be
depressed
62.8 2.83 (0.72) 2.65 (0.75) 3.00 (0.85) 2.95 (0.95) 2.54 (0.88) F4,87 ϭ 1.092,
p ϭ 0.366
Poor knowledge of what
to do if a patient could
be depressedb
56.4 2.83 (0.94) 2.60 (0.82) 2.83 (0.84) 2.90 (0.70) 2.04 (0.69) F4,88 ϭ 4.997,
p ϭ 0.001
Role limited to eye health
rather than emotional
wellbeingb
51.1 2.83 (1.12) 2.89 (.99) 2.00 (.85) 2.90 (.70) 2.00 (.94) F4,87 ϭ 5.265,
p ϭ 0.001
Patients’ reluctance to
discuss how they feela
51.1 3.27 (0.79) 2.85 (0.75) 2.25 (0.87) 2.76 (0.89) 1.75 (0.75) F4,88 ϭ 2.843,
p ϭ 0.029
Lack of time to talk with
patientsa
50.0 3.27 (0.79) 2.85 (0.75) 2.25 (0.87) 2.76 (0.89) 1.75 (0.75) F4,87 ϭ 10.425,
p Ͻ 0.001
No ongoing contact with
patients to notice
changes in moodb
47.9 3.58 (0.90) 2.55 (0.76) 2.67 (0.99) 2.48 (0.93) 1.96 (0.69) F4,88 ϭ 8.154,
p Ͻ 0.001
High workloadb
44.7 3.00 (1.0) 2.75 (0.72) 2.17 (0.84) 2.52 (0.87) 1.79 (0.74) F4,87 ϭ 6.746,
p Ͻ 0.001
Work environment is not
suitable for private
discussions about
emotional wellbeingb
35.1 3.33 (0.65) 2.10 (0.91) 1.75 (0.87) 2.33 (0.97) 1.71 (0.81) F4,88 ϭ 8.380,
p Ͻ 0.001
Management does not
believe that detecting
depression is part of
work role
31.9 2.33 (0.89) 2.12 (0.93) 1.80 (0.79) 2.33 (0.86) 1.86 (0.97) F4,83 ϭ 1.315,
p ϭ 0.271
Need to protect oneself
from involvement with
patients’ emotional
problems
21.3 3.00 (1.0) 2.75 (0.72) 2.17 (0.84) 2.52 (0.87) 1.79 (0.74) F4,88 ϭ 1.062,
p ϭ 0.181
Reluctance by
management to listen
to concerns about
depression
11.7 1.75 (0.87) 2.00 (0.89) 1.60 (0.52) 1.65 (0.75) 1.52 (0.89) F4,80 ϭ 0.921,
p ϭ 0.456
Post hoc comparisons for professional group differences were computed using Tukey’s honestly significant difference (HSD) test. The
following Likert scale was used: 1, “strongly disagree”; 2, “somewhat disagree”; 3, “somewhat agree”; and 4, “strongly agree.”
ON, ophthalmic nurses; OPH, ophthalmologists; OPT, optometrists; ORT, orthoptists; RW, rehabilitation worker.

Our results suggest that training should be made available to all
new and existing staff because time and extent of clinical experi-
ence were not related to behavior, and, in fact, our findings indi-
cated that staff with greater experience are more likely to avoid
discussing patients’ emotional wellbeing. Training should also be
delivered in such a way as to enhance knowledge about the signif-
icance of consequences of depression and effectiveness of treat-
ment, to enhance participants’ confidence and skills in detecting
depression, and to assist participants to overcome barriers to re-
sponding to depression. This will require active involvement in
TABLE 5.
Preferences for training and future practice reported by each professional group
Training needs and
future practice
Total % of
participants who
agreed with this
statement (n ϭ 94)
Mean (SD)
ON OPH OPT ORT RW
I would like to be able to
refer patients I am
concerned about to
appropriate services
94.7 3.67 (0.49) 3.60 (0.50) 3.50 (0.91) 3.45 (0.80) 3.54 (0.64) F4,89 ϭ 0.242,
p ϭ 0.914
I would like to improve my
knowledge and awareness
of the services and
treatment options for
people with depressiona
90.4 3.58 (0.67) 2.75 (0.72) 3.58 (0.67) 3.64 (0.49) 3.32 (0.77) F4,89 ϭ 5.366,
p Ͻ 0.001
identify depression more
easily
87.2 3.33 (0.78) 3.00 (0.46) 3.58 (0.67) 3.23 (0.61) 3.14 (0.71) F4,89 ϭ 1.731,
p ϭ 0.150
I would like more information
about the signs and
symptoms of depression in
people with vision
impairmenta
86.2 3.42 (0.67) 2.65 (0.88) 3.83 (0.39) 3.45 (0.59) 3.11 (0.79) F4,89 ϭ 6.411,
p Ͻ 0.001
I would like to enhance my
communication skills for
working with depressed
patientsa
83.0 3.42 (0.79) 2.50 (0.76) 3.42 (0.67) 3.14 (0.83) 3.29 (0.60) F4,89 ϭ 4.991,
p ϭ 0.001
I would like guidelines in my
workplace for what to do
when I suspect someone
has depressionb
78.7 3.50 (0.37) 2.63 (0.83) 3.50 (0.67) 3.27 (0.88) 3.21 (0.78) F4,88 ϭ 3.327,
p ϭ 0.014
I would like to attend a
professional development
event to improve my
knowledge and skills for
managing patients with
depressiona
76.6 3.50 (0.67) 2.20 (0.89) 3.50 (0.67) 2.91 (0.92) 3.32 (0.61) F4,89 ϭ 9.121,
p Ͻ 0.001
educate patients and their
families about depressionb
64.9 3.17 (0.72) 2.50 (0.83) 3.33 (0.65) 2.82 (0.91) 2.75 (0.79) F4,89 ϭ 2.596,
p ϭ 0.042
I would like to discuss
patients’ feelings more
oftena
58.5 3.42 (0.67) 2.30 (0.92) 2.92 (0.52) 2.68 (0.89) 2.36 (0.56) F4,89 ϭ 5.7544,
p Ͻ 0.001
I would like to use a
depression screening tool
with my patientsc
55.3 3.33 (0.65) 2.40 (0.68) 3.17 (0.72) 2.41 (0.96) 2.50 (0.88) F4,89 ϭ 4.477,
p ϭ 0.002
Post hoc comparisons for professional group differences were computed using Tukey’s honestly significant difference (HSD) test. The
following Likert scale was used: 1, “strongly disagree”; 2, “somewhat disagree”; 3, “somewhat agree”; and 4, “strongly agree.”
Significant differences between groups are noted using a
p Յ 0.001, b
p Յ 0.05, and c
p Յ 0.01.
ON, ophthalmic nurses; OPH, ophthalmologists; OPT, optometrists; ORT, orthoptists; RW, rehabilitation worker.

training (e.g., group discussions, case studies, and practical experi-
ence) in addition to information provision. Training should also be
supplemented with the availability of appropriate resources that are suit-
ablefordistributiontopatients.Currently,only1⁄4 ofparticipantsprovide
information and education about depression to their patients, although
there is a strong desire to do so.
To our knowledge, this is the first quantitative study to investi-
gate how EHPs and RWs manage depression in patients with
vision impairment. Despite a detailed consultation process to en-
hance recruitment, the response rate for this survey was poor.
However, the response rate is similar to other studies on EHPs,38
and the large proportion of female participants also reflects the
nature of this profession. Of more concern is that this study is likely
to have attracted those with an interest in depression and may
therefore portray an optimistic view about current practice and
desire for training. We also acknowledge that this study collected
only self-reported data and participants’ retrospective recollections
of consultations. We attempted prospective data collection in this
study by requesting that participants record details of the consul-
tations in which they suspected a patient may be depressed. We
specifically asked participants to record what had raised their con-
cerns about the patients and what actions they took. However, too
few forms were returned to be reported (a total of 18).
On the basis of our results, we are currently developing a train-
ing program for EHPs located at a tertiary eye care hospital. We
will evaluate the impact of this training on confidence, perceived
barriers, and behavior. Further work is required to determine pa-
tients’ reactions to depression screening in eye-care and vision re-
habilitation services; preferences for information and care; care
pathways following referral; and uptake and outcomes of services.
ACKNOWLEDGMENTS
We thank all participants who took part and the following bodies who worked
with us to design and disseminate the survey: Optometrists Association Aus-
tralia Victoria; Australian Ophthalmic Nurses Association; Royal Australian
and New Zealand College of Ophthalmologists; Australian Orthoptic Board;
Vision Australia; and Guide Dogs Victoria.
This work was supported by beyondblue: the national depression initiative.
Received June 17, 2009; accepted August 6, 2009.
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Gwyn Rees
Department of Ophthalmology
Health Services Research Unit
Centre for Eye Research Australia
University of Melbourne
Locked Bag 8, East Melbourne
Victoria 8002, Australia
e-mail: grees@unimelb.edu.au

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