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Contents Monthly Volume 10 Number 6 June 19, 2020

MINIREVIEWS
125 Neuropsychiatric issues after stroke: Clinical significance and therapeutic implications
Zhang S, Xu M, Liu ZJ, Feng J, Ma Y

ORIGINAL ARTICLE
Observational Study
139 Visual impairment and depression: Age-specific prevalence, associations with vision loss, and relation to life
satisfaction
Brunes A, Heir T

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Submit a Manuscript: https://www.f6publishing.com World J Psychiatr 2020 June 19; 10(6): 139-149

DOI: 10.5498/wjp.v10.i6.139 ISSN 2220-3206 (online)

ORIGINAL ARTICLE

Observational Study
Visual impairment and depression: Age-specific prevalence,
associations with vision loss, and relation to life satisfaction

Audun Brunes, Trond Heir

ORCID number: Audun Brunes Audun Brunes, Trond Heir, Section for Trauma, Catastrophes and Forced Migration - Adults
(0000-0002-0806-5963); Trond Heir and Elderly, Norwegian Centre for Violence and Traumatic Stress Studies, Oslo NO-0484,
(0000-0001-9616-0145). Norway

Author contributions: Brunes A Trond Heir, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, NO-
contributed to data analysis, 0315, Norway
interpretation, writing the article,
and formatting; Heir T contributed Corresponding author: Audun Brunes, PhD, Research Scientist, Section for Trauma,
to study conception, study design, Catastrophes and Forced Migration - Adults and Elderly, Norwegian Centre for Violence and
data analysis, interpretation, Traumatic Stress Studies, PB 181 Nydalen, Oslo NO-0409, Norway. audun.brunes@nkvts.no
writing, and final approval of
article.

Supported by the European

Commission, Directorate-General Abstract
for European Civil Protection and BACKGROUND
Humanitarian Aid Operations, No. To our knowledge, no study has obtained specific estimates of depression for
ECHO/SUB/2015/718665/PREP1
7; and the Norwegian Association
young and middle-aged adults with visual impairment (VI). As estimates of
of the Blind and Partially Sighted, depression varies across age groups in the general population, it is of interest to
No. S23/2017, No. S20/2018 and examine whether the same applies to adults with low vision or blindness.
No. S12/2019.
AIM
Institutional review board To estimate depression prevalence and its association with VI-related
statement: The Regional characteristics and life satisfaction in adults with VI.
Committee for Medical and Health
Research Ethics gave permission to METHODS
carry out the study in accordance
A telephone-based cross-sectional survey was conducted between January and
with procedures for anonymized
data (Reference number: May 2017 in an age-stratified sample of adults who were members of the
2016/1615A). Norwegian Association of the Blind and Partially Sighted. Participants were
asked questions about their sociodemographic characteristics, VI characteristics,
Informed consent statement: All and life satisfaction. Depression was measured with the Patient Health
participants gave their informed
Questionnaire. The diagnostic scoring algorithm was used to calculate the point
consent to take part in the study.
prevalence of depression (i.e., major depression and other depressive disorders)
Conflict-of-interest statement: No across categories of gender and age (years: 18-35, 36-50, 51-65, ≥ 66). The
potential conflict of interest was associations were estimated using regression models.
reported by the authors.
RESULTS
Data sharing statement: Data are Overall, 736 adults participated in the study (response rate: 61%). The prevalence
from the research project European
estimates of depression varied across different age groups, ranging from 11.1%-
Network for Psychosocial Crisis
Management – Assisting Disabled 22.8% in women and 9.4%-16.5% in men, with the highest rates for the two
in Case of Disaster (EUNAD). youngest age groups. Results from the multivariable models including
Public availability may comprise sociodemographic and VI-related variables showed that losing vision late in life
the privacy of the participants. [Prevalence ratio (PR), 1.76, 95%CI: 1.11, 2.79] and having other impairments (PR:
According to the informed consent

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 Brunes A et al. VI and depression

given by each participant, the data 1.88, 95%CI: 1.32, 2.67) were associated with higher rates of depression, whereas
are to be stored properly and in older age was associated with lower rates (PR: 0.83, 95%CI: 0.74, 0.93).
line with EU Regulation 2017/679
(General Data Protection
Additionally, participants who were depressed had lower life satisfaction than
Regulation (GDPR)). However, those who were not depressed (adjusted β: -2.36, 95%CI: -2.75, -1.98).
anonymized data is available to
researchers who provide a CONCLUSION
methodologically sound proposal Our findings suggest that depression in adults with VI, and especially among
in accordance with the informed young and middle-aged adults, warrants greater attention by user organisations,
consent of the participants. clinicians, and healthcare authorities.
Interested researchers can contact
project leader Trond Heir
(trond.heir@medisin.uio.no) with a Key words: Blindness; Depression; Life satisfaction; Major depression; Vision loss;
request for our study data. Visual impairment
STROBE statement: The authors
have read the STROBE Statement- ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
checklist of items, and the
manuscript was prepared and Core tip: Depression in people with visual impairment (VI) goes often unrecognized and
revised in accordance with the untreated, yet knowledge about its occurrence can help to inform the design of mental
STROBE Statement-checklist of
health services targeting the specific population. The study’s findings of a high rate of
items.
depressive disorders in adults with VI, particularly among young and middle-aged
Open-Access: This article is an adults, should in part be interpreted in the light of the extensive stigma, discrimination,
open-access article that was isolation, and loneliness that they experience. For depressed adults with VI, the
selected by an in-house editor and consequences may be severe in terms of a lower quality of life.
fully peer-reviewed by external
reviewers. It is distributed in
accordance with the Creative
Commons Attribution Citation: Brunes A, Heir T. Visual impairment and depression: Age-specific prevalence,
NonCommercial (CC BY-NC 4.0) associations with vision loss, and relation to life satisfaction. World J Psychiatr 2020; 10(6):
license, which permits others to 139-149
distribute, remix, adapt, build
upon this work non-commercially,
URL: https://www.wjgnet.com/2220-3206/full/v10/i6/139.htm
and license their derivative works DOI: https://dx.doi.org/10.5498/wjp.v10.i6.139
on different terms, provided the
original work is properly cited and
the use is non-commercial. See:
http://creativecommons.org/licen
ses/by-nc/4.0/

Manuscript source: Unsolicited INTRODUCTION

manuscript
Visual impairment (VI) refers to a substantial and often irreversible loss in one of the
Received: January 31, 2020 functions of the visual system[1]. About 1.3 billion people are classified with near or
Peer-review started: January 31, distance VI on a global basis[2,3] and the numbers are projected to increase in the future
2020 due to an aging population and the greater burden of vision-threatening conditions
First decision: March 24, 2020 such as diabetes and stroke[2]. Researchers, clinicians and others often refer to VI as a
Revised: May 18, 2020 single entity, but VI is, in fact, a highly heterogeneous condition in terms of the visual
Accepted: May 21, 2020 function affected, onset age, severity, cause, and prognosis of vision loss. A distinction
Article in press: May 21, 2020 is often made between congenital and acquired vision loss, and between moderate VI,
Published online: June 19, 2020 severe VI and blindness[1].
The literature on depression in people with VI is quite extensive[4-12], with many
P-Reviewer: Vidal EIO studies suggesting a link between vision loss and depression[6-8,10,12]. However, the
S-Editor: Dou Y prevalence estimates for depression have been found to vary greatly across studies. A
L-Editor: A meta-analysis of depression or depressive symptoms in people with vision-related
E-Editor: Liu MY conditions revealed that the prevalence estimates ranged between 5% and 57%, with a
mean of 25%[12]. Much of the variation in the reported prevalence estimates is related
to the inclusion of small and non-representative samples. In addition, most of the
studies have been restricted to specific vision conditions or to older adults. Of studies
involving young and middle-aged adults from the VI population [8,11] , none have
estimated the prevalence of depression for these age groups. As estimates of
depression differ across different age groups in the general population[13,14], it is of
interest to examine whether the same applies to adults with low vision or blindness.
Most studies of people with VI have relied on symptom rating scales in their
screening for depression, while few studies have estimated the prevalence of
depressive disorders[12,15,16]. Although clinical interviews are considered the gold
standard for diagnostic classification, the impracticability of interviews in large
surveys has led to the development of brief screening tools that match the criteria set
in official diagnostic systems. One such questionnaire is the nine-item Patient Health
Questionnaire (PHQ-9)[17]. The PHQ-9 has been applied in research on people with
various health conditions[18]. Furthermore, the operational characteristics of the PHQ-9
are either equal or superior to other depression measures[18], and the results of a recent

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 Brunes A et al. VI and depression

meta-analysis, which included 40 studies, have confirmed its validity as a diagnostic

measure in primary care settings (sensitivity: 41%-71%; specificity: 88%-97%)[19].
There is little consensus in the literature about whether there are certain subgroups
of the VI population at greater risk of developing depression than others. Earlier
research has mostly focused on the association between the severity of vision loss and
depression [4,7,9,11,16,20-22] , often finding no relationships [4,5,7,11,20-22] , whereas more
inconsistent evidence has been reported for factors such as the duration and cause of
vision loss[4,9,22]. Furthermore, we have not identified any publications related to the
risk of depression among adults with congenital or childhood vision loss, and more
research is therefore needed.
We conducted a cross-sectional study that included a large, age-stratified sample of
Norwegian adults with VI. Data were obtained via structured telephone interviews,
and the PHQ-9 was used to obtain a probable diagnosis of current depression. This
study had three main aims: To estimate the point prevalence of depressive disorders
in stratified age groups of adults with VI; to examine whether depression was
associated with different characteristics of vision loss; and to describe the association
between depression and life satisfaction.

MATERIALS AND METHODS

Ethical considerations
The Regional Committee for Medical and Health Research Ethics was sought, and the
committee confirmed that the study required no formal ethical approval as it was
carried out in accordance with principles of anonymized data (Reference number:
2016/1615A). Prior to the survey, the participants were informed about all aspects of
the research project, including potential risks and the voluntary nature of the survey.
The participants consented by completing the interviews. No identifying information
was collected.

Design and participants

An anonymous cross-sectional survey was conducted in an age-stratified sample of
adult members (aged ≥ 18 years) of the Norwegian Association of the Blind and
Partially Sighted. For a person to be granted full membership of the organization, he
or she needs to enclose in their application form medical documentation of either VI
or an untreatable eye condition that will progress towards low vision or blindness.
Data were collected between January and May 2017, through structured telephone
interviews. The interview guide contained more than 120 questions covering a wide
range of topics, including sociodemographic factors, cause and onset of vision loss,
serious life events, coping, mental health, and quality of life. Each interview took
about 30 min to complete.
Most people with VI are of old age[1]. We therefore used an age-stratified sampling
technique to allow for more precise estimations across all age groups in the adult VI
population. First, the study population was divided into four age groups (years: 18-
35, 36-50, 51-65, ≥ 66) and then we surveyed an equal number of members across the
different age groups. The sample size calculations showed that it was desirable to
enrol about 200 participants to estimate a prevalence with a precision of ± 5%, at a
95% confidence interval (CI), within each age group[23]. The calculations were founded
on the assumption that the prevalence for different mental health outcomes would not
exceed 15% in the study population. We almost reached our target, ending up with
156-200 participants per age group. A flow chart of the sample selection is provided
elsewhere[24].

Assessment and evaluation

Depression: Depression was assessed by the nine-item PHQ depression module
(PHQ-9), with one item anchored to each of the nine symptoms required to establish a
probable diagnosis of depression (i.e., major depression and other depressive
disorder) based on the criteria listed in the Diagnostic and Statistical Manual of
Mental Disorders, fourth edition (DSM-IV)[18]. The PHQ-9 also matches the new DSM-
V criteria[25]. The participants were presented a list of nine symptoms, and instructed
to indicate how often they have experienced each symptom during the past two
weeks. The response alternatives were: (0) “not at all”; (1) “several days”; (2) “more
than half of the days”; and (3) “nearly every day”. In the study, the PHQ-9 had a
Cronbach’s alpha of 0.84.
We categorized depressive disorders using the DSM-based diagnostic algorithm
created by Spitzer et al [17] . To be classified with major depression, the algorithm
requires that at least five symptoms are scored as 2 (“more than half of the days”) (1,

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Brunes A et al. VI and depression

“several days” for the suicidal ideation item), in which one of the symptoms is
anhedonia or depressed mood. For other depressive disorders, two to four symptoms,
including anhedonia or depressed mood, are endorsed with a score of at least 2
(“more than half of the days”) (“several days” for suicidal ideation). A final item
assesses functional limitations caused by the depressive symptoms, and in our study,
it included the following four response alternatives: “No difficulties”, “somewhat
difficult”, “very difficult”, and “extremely difficult”. We categorized the item into a
dichotomous variable (“no difficulties”, “difficulties”).

Life satisfaction: Cantril’s Ladder of Life Satisfaction was employed in the

questionnaire to measure current life satisfaction[26]. The participants were asked to
imagine a ladder with 10 steps, with the bottom step representing the worst possible
life (a score of 1) and the top step representing the best possible life (a score of 10). The
scale was treated as an untransformed continuous variable in the main analyses.

Referral to psychologist: During the study it became apparent that the need for
professional help was large and unmet in the sample population. Based on early
feedback we received from the participants, we decided to offer referrals for
psychological counselling for the subsequent participants (421 of 736 participants).
Patients were referred to psychological counselling for subjectively experienced
mental disorder with the desire for professional help. The psychologist recorded the
number of participants who met for counselling and the main themes of the
consultations.

Independent variables: The participants were asked questions about their age (years:
18-35, 36-50, 51-65, ≥ 66), gender, education (years: < 11, 11-13, ≥ 14), native origin
(Norwegian, non-Norwegian), place of residence (village/town, small or large city),
the current status of their vision loss (stable, progressive), and whether they had other
impairments (no, yes). Moreover, the severity of vision loss was assessed by asking
the following question: “How good is your current vision (better-seeing eye, with
glasses or contact lenses)”. The question had the following response alternatives:
“blind”, “severely impaired”, “moderately impaired”, and “unspecified”. As only 42
participants reported unspecified VI, we chose to merge the unspecified VI category
with the category moderately impaired because we considered those participants to
have a lower degree of vision loss than those who reported severe impairment and
blindness. Lastly, we created an “age of VI onset” variable by subtracting the
participant’s age with the number of years since VI onset. The variable was
categorized into the following three categories: “Congenital”,
“childhood/adolescence (2-24 years)”, and “adulthood (≥ 25 years)”.

Statistical analysis
All statistical analyses were performed using Stata Version 15 (Stata Corp., Texas,
United States). The significance level was set at P = 0.05. Descriptive statistics
included frequencies and percentages, and differences in frequency counts were
assessed by Pearson’s chi-squared or Fisher’s exact tests. To account for the age-
stratified sampling method, we tested in all analyses whether the estimates varied
across the different age groups (years: 18-35, 36-50, 51-65, ≥ 66) by performing
statistical analyses of cross-tabulated data or by including a product term between age
and each independent variable in a regression model.
Depressive disorders involved major depression and other depressive disorders.
We estimated the point prevalence and corresponding 95% exact CIs for all depressive
disorders separately for women and men and for each of the four age groups. Next, to
explore differences between classification methods, we performed supplementary
analysis by using the sum score method of the PHQ-9 dichotomized into no or mild
depression (a sum score < 10) and moderate to severe depression (a sum score ≥ 10)[18].
A sum score of 10 or higher has been recommended as the most optimal cut-off in
screening for major depression[18,19].
Binomial generalized linear models with log-link function were used to derive
unadjusted and adjusted estimates of associations between the independent variables
(sociodemographic factors and VI characteristics) and depression[27]. The results were
presented in terms of prevalence ratios (PRs) and 95%CIs. We did not include national
origin and municipality size in the adjusted models because the full model resulted in
less accurate estimates of the independent variables[28]. To reduce the risk of sparse
data bias, we decided to model age (10-year intervals) and education as continuous
variables. This decision had minor impact on the model fit.
The association between depression and life satisfaction was estimated using linear
regression. The models were either unadjusted or adjusted for all indicated covariates.
Our data met all assumptions relating to linear regression, and we did not find any
impact from outliers or multi-collinearity on the main results.

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 Brunes A et al. VI and depression

Statistical review
The statistical methods of the study were reviewed by Ragnhild Sørum Falk, PhD,
Oslo University Hospital (e-mail: Rs@ous-hf.no).

RESULTS
A total of 1216 members were contacted, of which 736 participated (response rate:
61%). We had no additional sources of missing data; all participants answered all
questions and none of the participants chose to withdraw from the study after
completing the interviews. The characteristics of the VI population for women and
men are listed in Table 1. Women were more likely than men to be of non-Norwegian
origin and to have self-reported moderate VI. There were no gender differences in
age, education, native origin, place of residence, onset-age or current status of vision
loss, or whether the participants had any other impairments.

Point prevalence of depressive disorders

The results presented in Table 2 show the prevalence of depressive disorders in the VI
population according to participants’ age and gender. The point prevalence varied in
different age groups between 4.2% and 15.6% for major depression (women: 5.6%-
17.8%, men: 2.4%-12.9%), 4.0% and 6.2% for other depression (women: 3.8%-5.6%,
men: 3.5%-7.1%), and 10.3% and 19.9% for any depression (women: 11.1%-22.8%,
men: 9.4%-16.5%). Overall, the estimates were highest in the age group 36-50 years
and lowest in the age group 66 years or above. There were no statistically significant
differences between women and men (results not shown).
We then performed a supplementary analysis by estimating the proportion of the
study population with moderate to severe levels of depression. Although this type of
categorization resulted in higher rates of depression, the results from the analysis
supported our main findings of severe depression being most prevalent among the
youngest participants (Online Supplementary Table 1).

Associated factors of depression

The unadjusted and adjusted PRs for depressive disorders across different
characteristics of the VI population are listed in Table 3. Having addition
impairments, losing vision in adulthood, and having progressive vision loss were
associated with a higher prevalence of depression in the unadjusted models. In
contrast, lower rates of depression were found with older age. In the fully adjusted
models, the PRs did not change much after adjusting for age, gender, education, and
all indicated VI characteristics, except that the VI stability variable turned out to be
non-significant. Depression was not related to gender, education or the severity of VI.
There were no statistical interactions between age and any of the other independent
variables (P > 0.05).

Functional limitations
Eighty-seven percent of depressed participants reported functional limitations in
daily life, against 47% in those without depression. There was also a somewhat higher
rate of functional limitations among depressed participants in the two youngest age
groups (18-35 years and 36-50 years) than found among the older participants (P =
0.10).

Life satisfaction
The life satisfaction of participants with any depressive disorder was considerably
lower than that of participants without depression (mean: 4.64 vs 7.18, β -2.54, 95%CI:
-2.93, -2.16). The strength of the association remained similar after adjusting for age,
gender, education, national origin, municipality size, and each of the four VI variables
(β -2.36, 95%CI: -2.75, -1.98). None of the interactions involving age and the other
independent variables reached statistical significance (P > 0.05).

Referral to a psychologist
Among the 421 participants that were offered mental health care, 45 (10.7%)
participants had a consultation with a psychologist, with similar rates across the
different age groups (P = 0.91). Of the 45 referred to counselling, 30 (8.4%) had no
depression, 13 (28.9%) had major depression, and 2 (10.0%) had other depression (P <
0.001). The main themes of the consultations were related to minority stress and
struggles in handling stigma that had been internalized in many cases. Other
important themes were feelings of marginalization and the violation of basic human
rights. Some participants described that having VI involved feelings of anxiety.

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 Brunes A et al. VI and depression

Table 1 Characteristics of the sample by gender

Characteristics Total (n = 736), n (%) Women (n = 403), n (%) Men (n = 333), n (%) P value1

Age2 0.93
18-35 yr 157 (21.3) 88 (21.8) 69 (20.7)
36-50 yr 186 (25.3) 101 (25.1) 85 (25.5)
51-65 yr 200 (27.2) 106 (26.3) 94 (28.2)
≥ 66 yr 193 (26.2) 108 (26.8) 85 (25.5)
Education 0.20
< 11 yr 115 (15.6) 69 (17.1) 46 (13.8)
11-13 yr 286 (38.9) 162 (40.2) 124 (37.2)
≥ 14 yr 335 (45.5) 172 (42.7) 163 (49.0)
Native origin 0.006b
Norwegian 645 (87.6) 341 (84.6) 304 (91.3)
Non-Norwegian 91 (12.4) 62 (15.4) 29 (8.7)
Place of residence 0.21
Village/town 399 (54.2) 227 (56.3) 172 (51.7)
Small or large city 337 (45.8) 176 (43.7) 161 (48.3)
VI severity 0.05a
Moderate 254 (34.5) 155 (38.5) 99 (29.7)
Severe 296 (40.2) 152 (37.7) 144 (43.2)
Blindness 186 (25.3) 96 (23.8) 90 (27.0)
Age of VI onset 0.24
Congenital 330 (44.8) 118 (46.7) 142 (42.6)
Childhood/adolescence 142 (19.3) 69 (17.1) 73 (21.9)
Adulthood 264 (35.9) 146 (36.2) 118 (35.4)
Current VI status 0.06
Stable 523 (74.5) 275 (68.2) 248 (74.5)
Progressive 213 (25.5) 128 (31.8) 85 (25.5)
Other impairments 0.46
No 478 (64.9) 257 (63.8) 221 (66.4)
Yes 258 (35.1) 146 (36.2) 112 (33.6)

a
P < 0.05.
b
P < 0.01.
1
P-value derived from Pearson’s Chi-squared test.
2
The sample had a mean age of 51.4 years (SD: 17.2), 51.7 for women and 51.1 for men. VI: Visual impairment.

DISCUSSION
Key findings
In our cross-sectional study we found that the prevalence of having any depressive
disorder varied considerably across the four age groups, with 11%-23% in women and
9%-17% in men, and with highest rates for the youngest participants. Losing vision in
adulthood and having addition impairments were found to be independently
associated with increased rates of depression, whereas older age was associated with
decreased rates. Furthermore, participants who were depressed had considerably
lower life satisfaction compared with those who were not depressed.

Strengths and limitations

Our study is the largest study to date to address the prevalence of depression in VI
populations across the entire adult age range, and the first to report estimates of other
depressive disorder. The stratified sampling procedure made it possible to obtain
robust depression estimates in all four age groups. The use of telephone interviews,
the good response rate, and the lack of missing data increased the validity of the
study findings.
Our study had also some limitations. First, it relied on cross-sectional data, which
restricted our ability to make causal inferences about the observed associations.
Second, the rates of PHQ-defined depressive disorders were not validated by a
clinical interview and therefore the estimates reflected a probable diagnosis instead of

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 Brunes A et al. VI and depression

Table 2 The point prevalence of depressive disorders in the visual impairment population by age and gender

Disorders Cases/total Total (n = 736) (95%CI) Women (n = 403) (95%CI) Men (n = 333) (95%CI)

Major depression
18-35 yr 18/157 11.5 (6.9, 17.5) 12.5 (6.4, 21.3) 10.1 (4.2, 19.8)
36-50 yr 29/186 15.6 (10.7, 21.6) 17.8 (10.9, 26.7) 12.9 (6.6, 22.0)
51-65 yr 14/200 7.0 (3.9, 11.5) 7.6 (3.3, 14.3) 6.4 (2.4, 13.4)
≥ 66 yr 8/193 4.2 (1.8, 8.0) 5.6 (2.1, 11.7) 2.4 (0.3, 8.2)
P value 0.003b 0.05a 0.08
Other depression
18-35 yr 7/157 4.5 (1.8, 9.0) 4.6 (1.3, 11.2) 4.4 (0.9, 12.2)
36-50 yr 8/186 4.3 (1.9, 8.3) 5.0 (1.6, 11.2) 3.5 (0.7, 10.0)
51-65 yr 8/200 4.0 (1.7, 7.7) 3.8 (1.0, 9.4) 4.3 (1.2, 10.5)
≥ 66 yr 12/193 6.2 (3.3, 10.6) 5.6 (2.1, 11.7) 7.1 (2.6, 14.7)
P value 0.76 0.95 0.75
Any depression
18-35 yr 25/157 15.9 (10.6, 22.6) 17.1 (9.9, 26.6) 14.5 (7.2, 25.0)
36-50 yr 37/186 19.9 (14.4, 26.4) 22.8 (15.0, 32.2) 16.5 (9.3, 26.1)
51-65 yr 22/200 11.0 (7.0, 16.2) 11.3 (6.0, 18.9) 10.6 (5.2, 18.7)
≥ 66 yr 20/193 10.3 (6.5, 15.6) 11.1 (5.9, 18.6) 9.4 (4.2, 17.7)
P value 0.07 0.59 0.16

a
P < 0.05.
b
P < 0.01.

diagnosed depression. Researchers have been concerned about the possibility that
standard rating scales could overestimate the prevalence of depression in VI
populations, given that certain depressive symptoms and especially somatic
symptoms bear resemblance to complications of vision loss[4,7]. However, the PHQ
algorithm method used in our study may produce fewer false positives than
continuous cut-off scores, as it puts more weight on the core symptoms of depression
(i.e., depressed mood and anhedonia) and thus downplays the importance of somatic
symptoms. Third, there was a potential risk of misclassification of the VI
characteristics because some of the participants might not have known or been able to
recall specific details about their condition. We expect non-differential
misclassification, and in studies like ours, which include high-prevalent outcomes, the
magnitude of the bias is likely to be low and drawn towards the null value[29]. Fourth,
and lastly, because our sample was recruited from a member organization for the
blind and partially sighted, it may be questioned whether it was representative of the
broader VI population. However, the demographics of our sample were comparable
with the 2015 census data of people with self-rated vision loss provided by Statistics
Norway[30], except that our sample had a higher level of education. Since high levels of
education may protect against the development of depression, we assume that the
depression rates in our study were underestimated.

Comparison with the literature

To our knowledge, this is the first study of its kind to estimate the prevalence of
depressive disorders in young and middle-aged adults with VI. The 16% and 20%
rates in the respective age groups 18-35 years and 36-50 years were almost twice as
high as those obtained in similar age groups in a survey of the general United States
population in which depression was classified using the PHQ algorithm [28] .
Furthermore, the prevalence rates of major depression in the same age groups were
two to three times higher than the age-specific estimates for the general Western
European population [13,14] . We also found that the youngest adults had worse
outcomes than the older adults in terms of functional limitations. Our results illustrate
that visually impaired adults of young or middle age are at particular risk of
developing depressive disorders and that the demand for mental health care in these
age groups is substantial.
The prevalence rates of depressive disorders or major depression in our two oldest
age groups with VI were similar to those reported in earlier studies[4,5,7] or lower[9,10].
Furthermore, our depression rates did not differ from those reported elsewhere for
older adults in the general Western European population[13,14]. These findings reflect

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Brunes A et al. VI and depression

Table 3 Prevalence ratios for depressive disorders with sociodemographic factors and
characteristics of visual impairment estimated using regression analysis (n = 736)

Any depressive disorder

Variables
Cases/total % Unadjusted PR (95%CI) Adjusted PR (95%CI)

Age (continuous)2 - - 0.89 (0.81, 0.99)1 0.83 (0.74, 0.93)1

Gender
Men 42/333 12.6 1 [Reference] 1 [Reference]
Women 62/403 15.4 1.22 (0.85, 1.76) 1.17 (0.82, 1.68)
Education (continuous) - - 0.85 (0.72, 1.01) 0.86 (0.72, 1.02)
VI severity
Moderate 40/254 15.8 1 [Reference] 1 [Reference]
Severe 44/296 14.9 0.94 (0.64, 1.40) 0.87 (0.60, 1.32)
Blind 20/186 10.8 0.68 (0.41, 1.13) 0.82 (0.49, 1.36)
Age of VI onset
Congenital 35/330 10.6 1 [Reference] 1 [Reference]
1
Childhood/adolescence 26/142 18.3 1.73 (1.08, 2.76) 1.63 (1.03, 2.58)1
1
Adulthood 43/264 16.3 1.54 (1.01, 2.33) 1.76 (1.11, 2.79)1
Current VI status
Stable 65/523 12.4 1 [Reference] 1 [Reference]
1
Progressive 39/213 18.3 1.47 (1.02, 2.12) 1.43 (0.99, 2.06)
Other impairments
No 50/478 10.5 1 [Reference] 1 [Reference]
Yes 54/258 20.9 2.00 (1.41, 2.85)1 1.88 (1.32, 2.67)1

1
Results indicate statistical significance.
2
Rescaled into 10-year age intervals. VI: Visual impairment; CI: Confidence interval; PR: Prevalence ratio.

the mixed results of previous studies of elderly adults in which the aim was to
compare differences in estimates for visually impaired people and non-impaired
people[5,7,10].
We found that adults who acquired VI late in life and adults with other
impairments in addition to their vision loss had particularly high rates of depression.
Vision loss may result in dramatic changes to people’s lives and have implications for
daily life activities, such as driving and travelling outside the home. Depression may
develop as people struggle to cope with vision loss and its consequences for daily
life[15,16]. Such challenges may be even greater for those with additional impairments.
When people experience vision loss or receive a VI diagnosis, significant changes in
self-esteem, self-efficacy, identity, social relations, and well-being may occur[31]. Many
experience stress reactions such as shock, fear, frustration, helplessness, and grief[31],
and their future life prospects become distorted. By contrast, those who have lost their
vision earlier in life might have adapted to their vision loss during this period and
accepted their life situation.
The high rates of depression in people with vision loss should be discussed also in
the light of discrimination, stigmatization, alienation, and social isolation. Social
interaction is considered an integral part of a fully-fledged life, and unmet needs
could make life less pleasurable and less meaningful[32]. Loneliness and isolation are
common in VI populations[33]. Also, those populations are more likely than their
sighted peers to experience discrimination[34]. Exposure to negative social events may
induce feelings of alienation, persistent negative thoughts and mood, distorted
blaming of oneself and others, and loss of trust and faith in oneself and others[24]. Once
people experience negative social events or social exclusion, they may become socially
inactive or avoid certain situations in which they might experience further adverse
events. This could become part of a downward spiral, resulting in isolation,
loneliness, and depression[35].
We did not find any evidence of a relationship between self-reported VI severity
and depression, which is consistent with the literature on this subject[7,9,11,20-22]. For
example, in a survey of 1232 elderly outpatients from low vision rehabilitation
services, van der Aa et al[7] did not find any differences in depression rates across the
participants’ degree of visual acuity loss. Direct or self-reported measures of visual
functions may not capture the overall impact of a condition on people’s daily lives[1],

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 Brunes A et al. VI and depression

and moderate vision loss may be as challenging to manage as a more severe one[31].
Our finding of a strong association between depression and lower life satisfaction is
in accordance with documented findings relating to the general population [36,37] .
Although causality may be reversed in that people who are less satisfied with life may
be more likely be depressed, our findings probably point to the negative impact of
depression on several life domains.

Implications
Our findings suggest that the risk of depressive disorders is high among young and
middle-aged adults with VI. Vision loss can occur abruptly, resulting in a sudden loss
of function, or it may develop gradually over a longer period, accompanied by the
uncertainty about what the further development will cause. The high risk of
depression should receive greater public attention, and special attention should be
paid to adults of young age, the loss of vision in adulthood or those who have other
impairments in addition to their vision loss. Preventive strategies, such as improved
access to education, work, social services, and de-stigmatization programs, is also
warranted. Ophthalmologists and other professionals who face people with vision
loss should be aware of the high risk of depression and consider the need for referral
to mental health care.
Quite unintentionally, our survey revealed an unmet need for consultations with a
psychologist. People with vision loss may have a higher threshold when it comes to
seeking help due to personal concerns such as a desire for self-reliance or avoidance of
being labelled a “victim”. More importantly, there is a lack of knowledge among
health personal about the mental health adversities associated with VI[38], and to date,
special mental health care services for people who are blind or have low vision is
lacking in countries such as Norway. Thus, these issues should be addressed by both
health care authorities and user organizations in cooperation.

ACKOWLEDGEMENTS
The authors would like to thank Marianne Bang Hansen for her significant
contribution to study design and data collection. We also wish to thank our
collaborating project partners in the European Network for Psychosocial Crisis
Management – Assisting Disabled in Case of Disaster (EUNAD) for making it possible
for us to conduct our survey. Lastly, we would like to acknowledge the help of the
references group for the study for valuable feedback and discussions relating to the
main findings.

ARTICLE HIGHLIGHTS
Research background
People with visual impairment (VI) may be at risk of depression, but previous studies have
demonstrated inconsistent results and have either reported extremely low rates or reported rates
that ranged as high as 60%. Furthermore, previous studies of depression have mainly been
restricted to older people or to specific subgroups of the population.

Research motivation
Depression in this population goes often unrecognized and untreated. We have yet to fully
understand the magnitude of the problem and who is at particular risk of developing
depression. By obtaining more precise knowledge about the age-specific prevalence and
associated factors of depression, this information can be valuable in the design of preventive
efforts and to anticipate service needs.

Research objectives
We conducted a large, age-stratified study in the adult population of people with low vision or
blindness, with the following three main aims: (1) To estimate the point prevalence of depressive
disorders in stratified age groups of adults with VI; (2) To examine whether depression was
associated with different characteristics of vision loss; and (3) And to describe the association
between depression and life satisfaction. By doing so, we hoped to examine and better
understand the age-specific risk of depression among people with VI, as well as its associated
factors and potential consequences on people’s quality of life.

Research methods
The study was conducted as a cross-sectional interview-based survey between January and May
2017 and included an age-stratified sample of adults with VI. All participants were recruited
through the members list of the Norwegian Association of the Blind and Partially Sighted. A
total of 736 (61%) adults participated by completing the interview.

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Brunes A et al. VI and depression

Research results
The prevalence of depression in different age groups varied from 11.1%-22.8% in women to
9.4%-16.5% in men. The estimates were highest in the two youngest age groups, and these rates
were two times higher than those presented in previous studies of Westernized populations.
Additionally, we found that depression was independently associated with having other
impairments and loss of vision late in life, indicating that having difficulties in adapting to a new
situation of being visually impaired or blind may put people at increased risk of developing
depression. Lastly, depressed people in our study sample had considerably lower life satisfaction
and were more likely to be referred for psychological counselling than were people without
depression. The themes most often brought up by the participants during their consultations
with the psychologist were related to problems with minority stress and handling stigma. We
therefore argue that the high rates of depression in people with VI should be viewed in terms of
stigma, discrimination, loneliness, and isolation.

Research conclusions
To our knowledge, our study is the first to provide estimates of depression for the youngest part
of the adult VI population. We have identified some subgroups of the population at greater risk
of depression than others. Because of the high depression rates and their strong associations with
quality of life, we recommend the initiation of efforts that would improve access to professionals
trained in the needs and challenges of people with VI.

Research perspectives
Our research findings should be supported by future studies that include a large probability
sample of the entire adult VI population and that diagnose depression through clinical
interviews. Moreover, future research should involve measures of modifiable risk factors of
depression so that effective interventions can be designed to reduce the burden of depression for
this population.

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