Casten R, Rovner BW, Leiby BE, Tasman W. Depression Despite Anti–Vascular Endothelial Growth Factor Treatment of Age-Related Macular Degeneration. Arch Ophthalmol. 2010;128(4):506-508. doi:10.1001/archophthalmol.2010.24
Anti–vascular endothelial growth factor (VEGF) treatment has dramatically reduced the risk of severe vision loss in patients with age-related macular degeneration (AMD).1,2 Although about 30% of active-treated subjects in clinical trials gained 15 or more letters in visual acuity and 50% demonstrated improved mental health, many patients did not improve to this extent and did not experience improvements in mental health. Studies conducted prior to anti-VEGF therapy have noted that 30% of patients with AMD develop depression.3 New data are now needed to estimate depression rates in those currently being treated. To explore this issue, we conducted a pilot study of 51 patients with bilateral exudative AMD who were receiving ongoing anti-VEGF treatment.
Fifty-one subjects were recruited from the Retina Department, Wills Eye Institute. Medical records were reviewed and best-corrected visual acuity was recorded. Telephone assessments of patients' mood and self-reported vision function were ascertained at baseline and 3 months later. At baseline, patients had already received a mean (SD) of 7.4 (5.5) injections. The median was 6 injections (range, 1-25 injections). Depression was assessed using the Patient Health Questionnaire 9,4 which rates the severity of depressive symptoms based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition)5 criteria for depression. Scores range from 0 to 27; a score higher than 5 is clinically significant. Subjects completed the National Eye Institute Visual Function Questionnaire near and distance activity subscales and subjectively rated how helpful the injections have been (with scores of 1 [not at all helpful] to 4 [extremely helpful]).6 Subjects were also asked to indicate whether receiving injections was difficult because of transportation, costs, or anxiety.
The Table presents demographic information, baseline visual acuity and National Eye Institute Visual Function Questionnaire scores, and perceived benefit and barriers to treatment. The mean logMAR and National Eye Institute Visual Function Questionnaire scores show that subjects had substantial vision impairment. The majority of subjects (33 subjects [67%]) found the injections helpful; 13 subjects (25%), 8 subjects (16%), and 5 subjects (10%) cited transportation issues, anxiety, and costs, respectively, as obstacles.
At 3 months, 10 subjects (20%) had clinically significant depressive symptoms (mean [SD] Patient Health Questionnaire 9 score, 6.8 [1.6]). Compared with nondepressed subjects, depressed subjects had a greater decline in vision over 3 months (mean [SD] best-eye visual acuity change, 0.01 [0.26] vs −0.26 [0.37] logMAR, respectively; F = 5.76; P = .01). Depression was unrelated to changes in National Eye Institute Visual Function Questionnaire scores or obstacles to treatment.
This pilot study provides new data on rates of depression in patients with AMD who are currently receiving anti-VEGF treatment in the community. The prevalence rate of depression now appears to be lower than rates reported prior to the widespread use of anti-VEGF treatment. Nevertheless, 20% of patients had clinically significant depressive symptoms, particularly those whose vision worsened despite treatment. The limitations of this pilot study include the small sample, nonstandardized assessments of visual acuity, and telephone rather than in-person depression assessments. Nevertheless, we found a significant relationship between depression and worsening vision, which indicates the continued need for psychiatric and rehabilitative interventions for some patients with AMD who are receiving anti-VEGF treatment.
Correspondence: Dr Casten, Thomas Jefferson University, Jefferson Hospital for Neuroscience, 900 Walnut St, Fourth Floor, Philadelphia, PA 19107 (firstname.lastname@example.org).
Financial Disclosure: None reported.
Funding/Support: This work was supported by the Thomas Jefferson University Pilot Research Award.
Additional Contributions: The Wills Eye AMD Study Group provided assistance with recruitment of the sample and data collection. Members of this group include William E. Benson, MD, Gary C. Brown, MD, Jay L. Federman, MD, Mitchell S. Fineman, MD, David H. Fischer, MD, Sunir J. Garg, MD, Allen C. Ho, MD, Jason Hsu, MD, Richard S. Kaiser, MD, Alfred C. Lucier, MD, Joseph I. Maguire, MD, J. Arch McNamara, MD, Carl H. Park, MD, Carl D. Regillo, MD, Lov K. Sarin, MD, Arunan Sivalingam, MD, Marc J. Spirn, MD, William Tasman, MD, and James F. Vander, MD.