screening of consecutive patients of amd attending the retina 
 clinic of a tertiary level multispecialty hospital in north india 
 was done for 12 months .
the selection criteria comprised ( 1 ) 
 diagnosis of amd confirmed by consultant ophthalmologist , 
 ( 2 ) age 50 years or older at the time of intake , ( 3 ) no other 
 uncorrected eye disease causing significant visual loss , ( 4 ) 
 no cognitive impairment as defined by mini mental state 
 examination ( mmse)13 cutoff score of 23 ( cutoff scores relaxed 
 and supplemented by clinical assessment in illiterates and 
 persons with low vision ) and ( 5 ) no current alcohol abuse 
 defined by a score of 7 or less on alcohol use disorders 
 identification test ( audit).14 during this period , 72 patients were diagnosed to have 
 amd , of which three patients could not be traced .
out of 69 
 patients screened , eight were excluded due to significant ocular 
 comorbidity and two each were excluded due to significant 
 cognitive deficits and active alcohol use .
thus , from the initial 72 
 patients , a final figure of 53 ( 73.6% ) was arrived at .
the study 
 group and the patients who refused consent or could not be 
 traced were similar regarding sociodemographic characteristics 
 and visual acuity .
the protocol for this study was approved by the ethics 
 review board of the institute .
written informed consent was 
 obtained from all participants . a trained psychiatrist ( ab ) 
 conducted cross - sectional examinations , supervised by 
 senior psychiatrists ( pk , sk ) and a senior ophthalmologist 
 ( ag ) .
patients detected to have depression were offered the 
 option of treatment from the psychiatric outpatient unit of 
 the institute .
the patients were subjected to a two - stage evaluation for 
 depression , screening being done by geriatric depression scale 
 -15-item version ( gds-15).15 in patients scoring above the cutoff 
 score ( 4/15 ) , diagnosis of depression as per the fourth edition 
 of diagnostic and statistical manual of mental disorders 
 ( dsm - iv)16 criteria was confirmed by using structured clinical 
 interview for dsm - iv axis - i disorders , clinical version ( scid- 
 cv).17 this yielded diagnoses of major depressive episodes , 
 dysthymic disorder , recurrent depressive disorder , bipolar 
 depression , adjustment disorder and depressive disorder not 
 otherwise specified ( sub - classified into minor depression using 
 dsm - iv criteria).16 visual acuity was measured under standard light conditions 
 using snellens eye chart . for statistical analyses ,
scores were 
 transformed into the logarithm of the minimum angle of 
 resolution ( logmar scale),18 which is a logarithmic scale on 
 which an increase of 1 point represents a 10-fold drop of vision 
 on the snellen scale . whereas 20/20 and 20/200 represent 
 normal vision and legal blindness respectively on the snellen 
 scale , corresponding values on the logmar scale are 0.0 and 
 1.0 respectively .
geriatric depression scale-15-item version ( gds-15):15 the short version ( 15-item ) of the original 30-item scale was 
 used both as a screening measure and for rating the severity of 
 depression ( score range 0 - 15 points ) .
the use of the cutoff point 
 4/5 for the gds-15 produced sensitivity and specificity rates of 
 97.0% and 54.8% and positive and negative predictive values of 
 69.6% and 94.4% respectively , using dsm - iv diagnostic criteria 
 for depression.19 high sensitivity made it particularly suitable 
 as a screening measure .
the structured clinical interview for dsm - iv axis - i disorders , 
 clinical version ( scid - cv):.17 it is a semi - structured interview for making major dsm - iv 
 axis - i diagnoses and was used for the diagnosis of depressive 
 disorders . the present study utilized the modules of mood 
 episodes ( single ) , mood disorders ( unipolar / bipolar ) and the 
 section on adjustment disorders .
world health organization disability assessment schedule - ii 
 ( whodas - ii):20 the whodas ii is a multidimensional questionnaire used 
 for measuring the level of disability across various conditions 
 and interventions .
it is a 36-item , interviewer - administered 
 scale , with a score range of 1 to 5 for each item , with a higher 
 score indicating more disability .
it measures disability in six 
 domains , namely understanding and communication , getting 
 around , self care , getting along with people ( interaction ) , life 
 activities and participation in society .
daily living tasks dependent on vision ( dltv ) scale:21 it is a vision - specific functional index specially designed for 
 use in patients with amd .
it is a 24-item scale which measures 
 difficulty associated with each activity with possible responses 
 ranging from 4 ( no difficulty ) to 1 ( vision prevents the person 
 from doing the given activity ) .
the activities fall into several 
 broad categories including distance vision , intermediate 
 and near vision , binocularity , field of vision , light and dark 
 adaptation , and contrast sensitivity .
analysis was carried out using spss 12.0 for windows ( spss 
 inc , chicago , il usa ) .
descriptive analyses were computed in terms of mean and 
 standard deviation for the entire sample as well as for group 
 comparison between depressed and non - depressed patients . 

depressed patients were compared with those without 
 depression on various sociodemographic and clinical variables 
 using unpaired t test for parametric variables , and using 
 mann - whitney test and chi - square test for non - parametric 
 variables .
stepwise multiple 
 linear regression analysis was used to assess the contribution of 
 various independent variables to disability in the sample .
the 
 findings of regression analysis have been interpreted through 
 two methods : firstly by the percentage variance accounted 
 for in predicting the dependent variable by the independent 
 variables alone and in combination and secondly , by examining 
 the partial correlations of the residuals with the dependent 
 variable .
geriatric depression scale-15-item version ( gds-15):15 the short version ( 15-item ) of the original 30-item scale was 
 used both as a screening measure and for rating the severity of 
 depression ( score range 0 - 15 points ) .
the use of the cutoff point 
 4/5 for the gds-15 produced sensitivity and specificity rates of 
 97.0% and 54.8% and positive and negative predictive values of 
 69.6% and 94.4% respectively , using dsm - iv diagnostic criteria 
 for depression.19 high sensitivity made it particularly suitable 
 as a screening measure .
the structured clinical interview for dsm - iv axis - i disorders , 
 clinical version ( scid - cv):.17 it is a semi - structured interview for making major dsm - iv 
 axis - i diagnoses and was used for the diagnosis of depressive 
 disorders .
the present study utilized the modules of mood 
 episodes ( single ) , mood disorders ( unipolar / bipolar ) and the 
 section on adjustment disorders .
world health organization disability assessment schedule - ii 
 ( whodas - ii):20 the whodas ii is a multidimensional questionnaire used 
 for measuring the level of disability across various conditions 
 and interventions .
it is a 36-item , interviewer - administered 
 scale , with a score range of 1 to 5 for each item , with a higher 
 score indicating more disability .
it measures disability in six 
 domains , namely understanding and communication , getting 
 around , self care , getting along with people ( interaction ) , life 
 activities and participation in society .
daily living tasks dependent on vision ( dltv ) scale:21 it is a vision - specific functional index specially designed for 
 use in patients with amd .
it is a 24-item scale which measures 
 difficulty associated with each activity with possible responses 
 ranging from 4 ( no difficulty ) to 1 ( vision prevents the person 
 from doing the given activity ) .
the activities fall into several 
 broad categories including distance vision , intermediate 
 and near vision , binocularity , field of vision , light and dark 
 adaptation , and contrast sensitivity .
analysis was carried out using spss 12.0 for windows ( spss 
 inc , chicago , il usa ) .
descriptive analyses were computed in terms of mean and 
 standard deviation for the entire sample as well as for group 
 comparison between depressed and non - depressed patients . 

depressed patients were compared with those without 
 depression on various sociodemographic and clinical variables 
 using unpaired t test for parametric variables , and using 
 mann - whitney test and chi - square test for non - parametric 
 variables .
stepwise multiple 
 linear regression analysis was used to assess the contribution of 
 various independent variables to disability in the sample .
the 
 findings of regression analysis have been interpreted through 
 two methods : firstly by the percentage variance accounted 
 for in predicting the dependent variable by the independent 
 variables alone and in combination and secondly , by examining 
 the partial correlations of the residuals with the dependent 
 variable .
the total number of depressed patients was 14 out of 53 , 
 giving a prevalence of 26% . in the depressed group
( 14 cases ) , 
 the breakup was major depressive disorder , recurrent ( five 
 cases ) , dysthymia ( three cases ) , major depressive disorder , 
 single episode ( two cases ) , adjustment disorder ( two cases ) , 
 bipolar affective disorder ( one case ) and minor depression 
 ( one case ) .
the sociodemographic characteristics of the sample are 
 displayed in table 1 . in the sample
, only three subjects were 
 found to be living alone ( one in depressed group , two in non- 
 depressed ) and the rest were living with family members . 

the depressed and non - depressed groups did not differ 
 significantly on sociodemographic parameters .
majority 
 of the patients ( 57% ) had medical comorbidity ( common 
 conditions being hypertension , diabetes , and arthritis ) but 
 patients with and without depression did not differ on 
 this parameter .
patients of amd with 
 depression had poorer vision in the worse eye compared to 
 those without depression .
the 
 depressed group scored significantly higher ( indicating greater 
 disability ) in all domains of whodas except self care .
the 
 dltv composite total score ( mean : sd=83.11 : 14.17 vs. 71.37 : 
 9.50 ; p = 0.009 ) was significantly lower in the depressed group 
 compared to the non - depressed group , indicating a higher 
 vision - specific disability in the depressed group .
there was 
 no significant difference between the depressed and non- 
 depressed groups with regard to dltv item scores of near 
 vision and distant vision .
the correlations between depression , visual acuity , disability 
 ( whodas score ) and vision - specific disability ( dltv score ) 
 are shown in table 4 .
the severity of depression ( gds score ) 
 correlated significantly with visual acuity in the worse eye , 
 dltv scores and whodas scores .
in addition to depression 
 and visual functioning , disability ( whodas ) was related with 
 visual acuity .
the dltv scores correlated strongly with visual 
 acuity and health - related disability . in table 5 , general disability ( whodas total ) was considered 
 as a dependent variable , and severity of depression ( gds score ) , 
 vision - specific functioning/ disability ( dltv final ) , visual acuity , 
 gender and type of amd were considered as the independent 
 predictors of disability . in stepwise linear regression ,
gds total 
 ( f= 40.12 , p<0.001 ) , dltv final ( f= 20.89 , p < 0.001 ) and visual 
 acuity in better eye ( f= 4.46 , p= 0.04 ) emerged as significant 
 predictors of general disability among the variables considered . 
 the total variance of disability explained by depression ( gds 
 total ) , vision - specific disability ( dltv final ) and visual acuity 
 in the better eye in our sample was 44.0% , 16.5% and 3.3% 
 respectively , together explaining 63.8% of the variance .
after 
 correcting for sampling error ( adjusted r - square ) , the variance 
 explained was 61.6% .
it was evident from the regression model 
 that the severity of depression emerged as a better predictor of 
 disability than visual acuity .
in the current study 14 out of 53 patients had depression giving 
 a point prevalence of 26% .
this rate is significantly higher 
 compared to the rate of depression among non - institutionalized 
 older people which ranges from 8 - 16%.21 however , the rate is 
 lower compared to previous studies of depression in amd 
 patients.7,8 a possible explanation lies in the lower visual impairment 
 and lower age in our patients compared to previous studies , 
 representing a milder severity of amd in our sample . 

moreover , rovner et al.,8 assessed patients with recent and 
 acute visual loss which may understandably precipitate 
 depression in some cases .
brody et al.,7 included the category 
 of subsyndromal depression in their study which was not 
 included in the present investigation to maintain uniformity 
 of diagnosis . on removing this group ,
their prevalence rate 
 comes down to 27.2% , which is very similar to our rate of 26% . 

the fact that a large majority of the sample was living with 
 family reflects the adequacy of social support , which may also 
 protect against depression .
other factors contributing to lower 
 prevalence could be socio - cultural reasons like poor knowledge 
 about implications of amd and relatively lower limitation in 
 activities of daily living in the rural indian setup . in the current study ,
a majority of the depressed subjects ( 11 
 out of 14 ) had the diagnosis of major depressive disorder . in the 
 only other study which used a standardized tool for diagnosis,7 

only 22% of the depressed patients ( n=49 ) fulfilled the criteria 
 for major depressive disorder , the remaining ones being cases 
 of minor depression ( 61% ) and an undefined category of 
 subsyndromal depression ( 16% ) .
this large difference is 
 difficult to explain , but may partly be due to cultural factors 
 and differences in coping once depressive symptoms set in .
earlier studies have excluded patients with non - advanced 
 amd , using cutoff levels of visual acuity in both eyes .
however , 
 the knowledge of having a progressive , non - treatable disabling 
 disorder like amd , which will ultimately lead to loss of 
 valued activities , dependency and blindness , may itself act 
 as a stressor and induce depression , even in patients of amd 
 who do not have significant visual disability .
previous studies 
 have reported that personality trait ( neuroticism ) is a better 
 predictor of depression than visual acuity , which is at best a 
 weak predictor.7,22 - 26 thus , it is evident that excluding patients 
 on the basis of visual acuity alone is superfluous , as other 
 parameters also have an impact on depression .
additionally , 
 once the intake is restricted by using visual acuity cutoffs , 
 all subsequent correlations studied with visual acuity are 
 biased , as has been acknowledged.7 in order to override these 
 limitations our study did not use visual acuity as an exclusion 
 criterion . in the study population , high levels of disability were found 
 and depressed patients had more general and vision - specific 
 disability than non - depressed patients . the difference in vision- 
 specific disability
was maintained even after controlling for 
 general disability and visual acuity . on analysis of the subscales 
 of whodas - ii
, depressed patients showed more disability 
 on the composite total score as well as five out of six subscales 
 of whodas - ii , namely understanding and communication , 
 getting around , getting along with people , life activities and 
 participation in society .
in addition to general disability , the depressed group had 
 higher visual impairment in the worse eye compared to the non- 
 depressed group .
this may be due to the difference in the sample 
 selection procedure , as previous studies included patients of 
 amd with severe visual impairment only .
when we consider 
 the entire range of amd patients , it appears that visual acuity 
 is an important determinant of depression .
the depression scores ( gds ) had moderate to strong positive 
 correlation with the general disability scores as measured by 
 whodas - ii .
one explanation for this relationship is that 
 depression and disability are related constructs and there 
 is a lot of overlap in their assessment . for example , items 
 on mood , energy , activity , mobility , concentration , memory , 
 work , sex , sleep are common to both depression and disability 
 assessments . in the present study ,
multiple stepwise linear regression 
 analysis was employed to examine the effect of independent 
 predictors on health - related disability . in the present work , 

depression , vision - specific disability and visual acuity in the 
 better eye emerged as significant contributors to disability . 
 after adjusting for depression , visual acuity in the worse eye , 
 type of amd and gender
were not significantly associated with 
 disability as shown by exclusion from the regression model 
 as well as non - significant partial correlation .
moreover , it is 
 evident from the variance that depression is a more important 
 predictor of disability than visual acuity .
this is in line with 
 the findings of brody et al.7 however , disability , depression 
 and visual impairment are inter - related , and the direction of 
 causality can not be ascertained on the basis of cross - sectional 
 data . for instance , depression is a better predictor of disability 
 than visual acuity , but visual impairment may have been an 
 important mediator of depression in patients with amd .
the strengths of the study include consecutive sampling , 
 systematic assessment and two - stage diagnosis of depression 
 based on the gold standard dsm - iv criteria , and assessment 
 of disability using appropriate generic and disease - specific 
 instruments .
the limitations include cross - sectional design , 
 small sample size and lack of a separate control group . as the 
 study was clinic - based , the results can not be generalized to 
 community settings .
being a cross - sectional study , it was not 
 possible to assess the temporal relationship between onset of 
 depression , diagnosis of amd and significant loss of visual 
 acuity .
however , in our work , significant differences emerged 
 and in light of the limited power provided by the sample , the 
 relationships appear to be particularly robust .
the present study on depression and its correlates in 
 patients with amd is the first of its kind outside the us , and 
 strongly reinforces the growing notion that psychological 
 morbidity in this group of patients contributes significantly to 
 their disability .
diagnosis and appropriate 
 treatment of depression are of utmost importance in this high- 
 risk group .
longitudinal studies with larger samples are required to 
 examine the course and outcome of depression and the efficacy 
 of interventions in this group of patients . with an approach 
 that is patient - centered rather than disease - centered , the health 
 professionals can move closer to the goal of treating the whole 
 patient.27 it is expected that with provision of optimal care 
 through more integrated services , patients with amd can look 
 forward to a happier tomorrow .
 aims : to estimate depression in patients with age - related macular degeneration ( amd ) and study the 
 relationships among depression , visual acuity , and disability.materials and methods : it was a cross - sectional study with consecutive sampling ( n = 53 ) of patients with 
 amd aged 50 years and above attending the retina clinic of a tertiary care hospital in north india . 
 depression , 
 general disability and vision - specific disability were assessed in subjects meeting selection criteria . 
 
 assessments were done using the fourth edition of diagnostic and statistical manual of mental disorders 
 ( dsm- iv ) geriatric depression scale ( gds ) , structured clinical interview for dsm - iv axis -i disorders , 
 clinical version ( scid - cv ) , world health organization disability assessment schedule - ii ( whodas - ii ) and 
 daily living tasks dependent on vision scale ( dltv ) . non - parametric correlation analyses and regression 
 analyses were performed.results:out of 53 participants , 26.4% ( n = 14 ) met dsm - iv criteria for the diagnosis of depressive disorder . 
 
 depressed patients had significantly greater levels of general and vision - specific disability than non- 
 depressed patients . 
 general disability was predicted better by depression and vision - specific disability than 
 by visual acuity.conclusion:depression is a major concern in patients with amd and contributes more to disability than 
 visual impairment . 
Materials and Methods
Measures of depression
Measures of disability
Results
Discussion