Q&A: Mental health conditions underrecognized in patients with AMD
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Key takeaways:
- Patients with AMD have higher rates of anxiety and depression.
- Retina specialists need to discuss mental health conditions with patients.
Healio spoke with Aleksandra Rachitskaya, MD, a vitreoretinal surgeon and associate professor of ophthalmology at Cleveland Clinic Cole Eye Institute, about mental health conditions in patients with age-related macular degeneration.
Rachitskaya discussed mental health symptoms to watch for, when to refer patients to mental health specialists, the importance of increasing awareness of mental health conditions in patients with AMD and more.
Healio: What mental health conditions are associated with AMD?
Rachitskaya: When we think about macular degeneration, it is a spectrum of diseases. You can have early or intermediate macular degeneration, or you can have a more advanced form of macular degeneration such as neovascular AMD or geographic atrophy. When I talk with patients, I explain that when they come see me with intermediate macular degeneration, it can stay the same or it can progress to these advanced stages and that sometimes patients can have both neovascular AMD and geographic atrophy. So, I think in terms of patient experiences, those differ depending where on the spectrum they fall, and the more advanced disease, of course, results in more advanced comorbidities.
What is important to understand is that several factors contribute to mental health issues in AMD patients. Those relate to the way that macular degeneration might affect their functioning. Patients might have trouble reading or driving. That then translates into effects on the essential parts of their life, such as loss of independence, loss of ability to take care of most basic things — balancing a checkbook, cooking or reading recipes. Moreover, jt can lead to significant social isolation. In areas where public transportation is nonexistent, it may be difficult to see your friends, be engaged in social activities, go to the library or go play bingo. And if a patient has advanced macular degeneration, they might not feel safe to drive, or it might not be legal to drive. All of that has been shown to lead to higher rates of anxiety and depression in our patient population.
Healio: How can clinicians manage these conditions in patients with AMD?
Rachitskaya: This disease is based on the exam and imaging, but when I talk with my trainees, I always tell them that we treat people — we do not treat pictures. These are the patients who we see on a regular basis, a lot of them monthly, and sometimes we see them more than the primary care doctors see them. So, I think the most important thing is to start a conversation. Ask patients how their vision is doing and who is with them, and you get a sense of where they are at. They might say, “I drove in today. I came by myself,” “I’m having trouble driving,” or “This person had to bring me. It’s hard for me to get to this location.” Those simple questions can lead to, “I’m struggling with this,” and you will be surprised how much you can pick up from those conversations.
I recently had a patient who started crying and explained how challenging it is for her to do the things that she took for granted before. Starting that conversation with patients and developing it over several visits are the first steps to understanding how AMD might affect their quality of life.
Healio: How should clinicians approach conversations about mental health with patients newly diagnosed with AMD?
Rachitskaya: Once again, you get a feeling of where the patient is, and a lot of times acknowledging that what the patient might be feeling is normal and expected is helpful. It is important for a patient to feel that they are not alone is important. I see patients who come to me for a second opinion about macular degeneration, and a lot of them are scared. It gives them a lot of anxiety to hear about macular degeneration. If I am particularly concerned about a patient, their mood or level of depression, and their safety, that becomes a more acute issue. I think establishing rapport and then asking those questions are part of taking care of patients. I am not a psychiatrist or mental health provider, but it is important to have that conversation.
Healio: When should clinicians consider referring patients with AMD to a specialist for mental health symptoms?
Rachitskaya: I find that there are different levels of depression in patients with macular degeneration, so it does not always come up on the first visit. If I am not concerned that somebody is in significant trouble, I say, “Have you talked with your primary care doctor about this?” You would be surprised to hear that most patients say, “No, I haven’t talked with them about it.” Then I say, “I think it would be beneficial for you to talk with them, and I would be happy to send them a message.” The way we function and provide care, there are a lot of ways to communicate efficiently through electronic medical records and electronic medical systems.
For instance, during clinic, I can send a message, I can send a letter, or I can start a chat with their doctor and say, “I am concerned about this patient, and it is something you can discuss with them.” Obviously, if you are in a situation with somebody who is suicidal, you are not going to do that — you are going to send that patient to the emergency room. But I usually start with the primary care doctor. I don’t necessarily direct them straight to subspecialty care because I find there are other factors that might play a role.
The other important thing is to make sure that we can do everything in our power as ophthalmologists and retina specialists to help patients cope. The physician might provide fantastic treatment and control the fluid in neovascular AMD, but at the same time, the patient may struggle with vision. I work closely with a social worker who is the liaison with the local low-vision center, and so there is a way for patients to be seen by a low-vision specialist, which allows us to optimize the use of the vision that they do have to maintain their quality of life and independence. That is another big part that we should consider when taking care of patients with advanced AMD.
Healio: What is the importance of increasing awareness among clinicians of mental health conditions in patients with AMD?
Rachitskaya: It is quite important because I think it is underrecognized. When I look at my schedule by age, the percent of patients who are in their 70s, 80s and 90s is extremely high. I see a lot of patients in their 90s, and many are highly functioning and want to live a full and productive life. It behooves us to pay attention and make sure that we recognize where we can help. From the patient perspective, having depression or any type of mental disease can carry stigma, so it is important to normalize this for patients, try to find solutions and make sure that they understand that this is not uncommon and that they are not alone.
This is something that we see frequently, and we need to help patients seek care and not give up on treatment. With macular degeneration, there is so much we have to offer, and there are patients who have been treated now for many years and are able to maintain good functioning vision. Bringing awareness to this topic is key because it is underrecognized in this patient population.
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