Patients with AMD benefit from self-management training

La Jolla, CA-A self-management program for elderly patients with advanced age-related macular degeneration (AMD) has benefits lasting at least 6 months past the intervention, including improvements in mood and function and prevention of depression. The incidence of depression was significantly lower in the self-management group (p = 0.05) than in the control group at the 6-month follow-up, said Barbara L. Brody, MPH, director, Center for Community Ophthalmology, University of California, San Diego Shiley Eye Center.

Brody was the lead author of a study published in the January issue of Archives of Ophthalmology detailing the results of the 6-month follow-up of the effectiveness of the counseling program. She is also clinical professor, departments of ophthalmology and family and preventive medicine, UCSD.

The impetus for the self-management program, said Brody, came from Dr. Stuart Brown's concern for the quality of life of AMD patients and the authors' prior research that documented the devastating impact of advanced AMD on people's lives. Dr. Brown is chairman of the department of ophthalmology and director of the UCSD Shiley Eye Center.

Self-management program

In the cognitive portion of the self-management program, patients were given information about AMD by an ophthalmologist and information about community resources. The behavioral component included problem-solving skills training intended to help participants communicate with others about their disease, obtain assistance, encourage positive thinking, and become involved in meaningful activities.

"This was a carefully orchestrated program where we created a positive environment for the participants, guiding them through a series of graduated challenges where they increased their skills in dealing with this terrible disease," Brody said.

Approximately 24% of this group met the criteria for major or minor depression at baseline, she said.

"The depressed people were more disabled than the nondepressed, and it appeared that their depression contributed more to their disability than only the vision loss alone," Brody added.

The first follow-up took place immediately after the 6-week intervention. These post-intervention results, published in 2002, indicated that the self-management group had more improvement than the controls on measures of mood and function. Of particular note was that the degree of change was significantly greater for individuals who had been depressed at baseline compared with those who were not.

"We found that the people who were most depressed at the start of the program showed the most improvement. Their mood improved, and their function improved. We think that a key factor in the effects of the program may have been an increase in their self-efficacy, i.e., their self-confidence in their abilities," Brody said.

At 6 weeks, the improvement in self-efficacy correlated, although weakly, with improvement in mood and improvement in function.

"At 6 months we found that correlation was much stronger," she added.

The 6-month follow-up included 214 (84.9%) of the original subjects. Investigators found that results of the intervention had not diminished over time, which often happens with behavioral programs, but were sustained and in some cases had become more pronounced.

Participants in the self-management program showed significantly less emotional distress (p = 0.008), better function (p = 0.05), and increased self-efficacy (p = 0.006) compared with control subjects.

Secondary analyses of the data found no difference in the proportion of change from depression to nondepression between the intervention and control groups (10 [12.2%] of 82 subjects versus 14 [10.6%] of 132 subjects; p = 0.44). Brody pointed out that clinical depression is known to remit in some patients.