Modifying Cognitive-Behavioral Therapy for a Depressed Older Adult With Partial Sight: A Case Report.

Depression is a common mental health problem in older adults, especially among those suffering from visual impairment. A clinical case of an Indonesian older adult with retinal detachment (75% blindness) suffering from Major Depressive Disorder, based on Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) criteria, was reported. Her principal motivation to seek help was her depressive symptoms, as well as her husband's discomfort with her change. A modified standardized cognitive-behavioral therapy was delivered in eight sessions, and a clinically significant reduction of depressive symptoms was observed at the middle of the treatment (Session 5); symptoms were further reduced at follow-up. This case report showed that conventional evidence-based psychological treatment can be modified to handle mental health problems in people with visual impairments.

Introduction

Depression is a common mental health problem among people with visual impairment (Burmedi, Becker, Heyl, Wahl, & Himmelsbach, 2002). A study in Britain showed that people with visual impairment had a higher prevalence of depression compared with people with good vision, because people with visual impairment were more likely to experience problems with functioning, which in turn lead to depression (J. R. Evans, Fletcher, & Wormald, 2007).

In managing depression with psychological therapy, cognitive-behavioral therapy (CBT) is known to be effective in a wide age range of patients around the world, including late adulthood (Serfaty et al., 2009). Specifically, short group CBT has been shown to reduce depressive symptoms in depressed Indonesian older adults (Utoyo et al., 2013). However, in cases involving older adults with physical disabilities, such as visual impairment, it was recommended that aspects of the therapy should be modified to suit the impairment (C. Evans, 2007). This case report aims to report on the results of modifying a standardized CBT for depression to suit a severe visual impairment condition suffered by an Indonesian older adult.

Case Presentation

A 77-year-old Indonesian woman who was a retired kindergarten teacher with retinal detachment (75% blindness) was diagnosed with Major Depressive Disorder based on Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) criteria. She had no mental health treatment history and was currently not in any kind of non-pharmacological intervention, either exercise or psychosocial. Her change in personality and habit motivated her husband to seek professional help for her and contacted a psychologist to examine her at home. The patient lived with her husband in a house in Depok, West Java, Indonesia. Her retinal detachment condition started at 2009 due to a head trauma, complicated with previous cataract surgery and severe anemia. Since then, her visual condition worsens through time. At the time of the examination, which was in 2012, she had 75% bilateral blindness according to her ophthalmologist’s diagnosis. According to her ophthalmologist, managing her visual condition required a surgical procedure that was very risky for her age. She and her husband decided that she not take the surgery. Therefore, her ophthalmologist only prescribed her with vitamins to manage her eye condition. Separately, she took medicine for her anemia as prescribed by her internist. Other than her visual condition and anemia, she did not report to have other medical or psychiatric condition. She also did not have other health care–related consumption. Her husband complained that her partial sight condition changed her into a different person: She lost self-confidence and refrained from going outside. She, however, had a different complaint: She felt frustrated due to her failure in doing daily activities (such as cooking and preparing food).

Ethical Statement

This study was a clinical case, approved and conducted under supervision of a senior clinical psychologist and lecturer from the Faculty of Psychology, University of Indonesia, Depok, Indonesia. Written informed consent from the patient and her husband were obtained in the first meeting of initial assessment.

Assessment

The main measurement tools for this study were the depression assessments: Indonesian version of Beck Depression Inventory (BDI; Suwantara, Lubis, & Rusli, 2005) and Indonesian back-translated Geriatric Depression Scale (GDS; Yesavage et al., 1983). There were three measurement points: baseline, mid-test at 3rd week of the treatment, and posttest at 1 week after the end of treatment (5 weeks from baseline).

In addition, mini mental status examination (MMSE; Folstein, Folstein, & McHugh, 1975) was conducted as part of the initial assessment to assess for possible cognitive impairment that may prevent her to follow the therapy. All assessments were done by one therapist (RA).

Intervention

Following depression diagnosis of the patient obtained from the pre-test result, an evidence-based psychological treatment, CBT, is chosen. CBT has been shown to be effective in treating depression for older adults, especially because the aim of CBT is to help the patient identify, challenge, and alter maladaptive thinking (Scogin, Welsh, Hanson, Stump, & Coates, 2005).

The treatment was based on a treatment manual that has been previously shown to be able to reduce depressive symptoms (Utoyo et al., 2013). It consists of eight sessions of 120 min each, and two sessions were given per week (every 3 to 4 days). The content of the therapy were psychoeducation about depression and CBT itself, activity scheduling and monitoring, relaxation techniques, cognitive restructuring, and problem-solving techniques.

The treatment was modified to suit the patients’ partial sight condition by recording all the materials into a CD. This approach was taken because the patient was known to operate a CD player regularly to listen to music. This modification of the treatment manual (Utoyo et al., 2013) was done under all authors’ permission. Also, all necessary adaptation to be used in the present study setting had been discussed. Other concurrent interventions were allowed, but the patient did not report engaging in any other interventions. For the written section of the treatment (“homework,” in CBT terminology), the patient did it with her husband’s or the therapist’s assistance twice every week. The homework included, for example, regular breathing relaxation and progressive muscle relaxation exercise, daily mood monitoring and activity planning, as well as cognitive restructuring with her husband’s or therapist’s assistance.

Results

The patient showed no significant cognitive impairment. Although reduced memory function was found, the condition can still be categorized as a result of normal aging process, according to the MMSE norms for the patient’s age group. Due to the absence of significant cognitive impairment, no contra-indication for using CBT was found. Therefore, the patient was deemed to be suitable to receive CBT for depression.

The depression level of the patient gradually declined across three measurement points for the BDI and GDS (Figure 1). At baseline, the patient’s depressive symptoms scores were categorized as severe depression (BDI, 25) and moderate depression (GDS, 20) using their respective norms. Then, at posttest, the patient’s BDI score was reduced to mild or moderate depression (BDI, 14), and her GDS score was reduced to no depression (GDS, 10). This can be considered as a clinically significant reduction of depressive symptoms. Furthermore, at posttest, the patient reported that she was sleeping normally, no longer felt depressed, regained her self-confidence, regained her interest to be active, and regained her appetite. Furthermore, she was also no longer experiencing ulcer and itchiness (psychosomatic symptoms), which she previously had.

Figure 1.

Outcome measures during treatment.

Discussion

This case report showed that modification of a conventional evidence-based psychological treatment to suit the patient’s visual impairment condition can reduce depressive symptom. With this result in mind, it is suggested that modifying a currently available evidence-based treatment to suit patient’s condition, rather than inventing a new one, is a reasonable approach.

In addition, this case report provides an illustration of depressive symptoms on visually impaired depressed Indonesian older adult. The patient experienced conventional symptoms of depression commonly found in patients in Western cultural context, such as feeling depressed, having difficulty sleeping, losing appetite, and losing self-confidence (e.g., Rush, Carmody, & Reimitz, 2000; Rush et al., 1986). This case report runs counter to the notion that depression is a uniquely Western phenomenon (Jadhav, 1996), although there is a slight difference of symptom presentation in common depressive patients in Western cultural context. The patient was primarily concerned about her ulcer and sleep difficulty (psychosomatic symptom). This similar emphasis on somatic symptom is also observed on Chinese depressive patients in China, although, interestingly, such emphasis is not found in White Americans or Chinese in the United States (Yen, Robins, & Lin, 2000).

Limitations, however, have to be taken into account in interpreting the findings. Assessments and therapy were conducted by one person. This introduced confirmation bias. However, this limitation was compensated with the gain of rapport and trust. Furthermore, this setting preserves external validity as it mimics everyday psychologist practice in Indonesia

To sum up, this case report showed that the patient with visual impairment experienced functioning problem, which leads to depression. This observation confirms the findings of Burmedi et al. (2002) and J. R. Evans et al. (2007), who found that people with visual impairment have functioning problem and higher depressive symptoms. Therefore, screening and treating depression in people with visual impairment is important. In the absence of available appropriate psychological treatment, this case report showed that it is possible to modify current evidence-based treatment to suit the need of the patient. This is probably no longer needed, once the planned trial on psychological treatment for depression on people with visual impairment is successful (Margrain et al., 2012).