Psychosocial Intervention for Age- Related Macular Degeneration: A Pilot Project Hans-Werner Wahl, Annette Kämmerer, Frank Holz, Daniel Miller, Stefanie Becker, Roman Kaspar, and Ines Himmelsbach
Abstract: This study evaluated an emotion-focused and a problem-focused in- tervention designed for patients with age-related macular degeneration. It found a limited decrease in depression in the emotion-focused group and an increase in active problem orientation and in adaptation to vision loss in the problem- 2p from Abstract bottom rule focused group. to base of first line of text
The emotional consequences of age- lated macular degeneration (AMD), has related vision loss, including reduced lev- been identified as an unmet need in the els of well-being and positive affect and field of ophthalmological treatment, re- greater levels of depression and negative habilitation, and education (Birk et al., affect, have been reported in the litera- 2004; Crews, 2000; Harshbarger, 1980; ture (see, for example, Burmedi, Becker, Horowitz & Reinhardt, 2000). Research- Heyl, Wahl, & Himmelsbach, 2002; Horo- ers have found that AMD is associated witz & Reinhardt, 2000). Longitudinal with significantly lowered functional research has shown that behavioral and ability, increased depression, and loss of emotional adjustment in older adults who psychological control (Brody et al., 2001; are visually impaired (that is, are blind or Rovner, Casten, & Tasman, 2002; Wahl, have low vision) worsens over time (Heyl Becker, Burmedi, & Schilling, 2004). & Wahl, 2001; Wahl, Schilling, Oswald, AMD has become the target of con- & Heyl, 1999). The provision of psycho- trolled research on psychosocial interven- social services to older adults to counter- tions in the past 10 years. Brody et al.’s act the negative emotional consequences (1999) randomized clinical trial of the ef- of visual impairment, including age-re- ficacy of a self-management intervention for elderly patients with AMD, consisting This study was supported by a grant from the of six weekly two-hour group sessions Wilhelm Woort Foundation for Aging Re- with 7–10 participants in each group, re- search awarded to the first three authors. The vealed that the participants experienced authors thank the ophthalmologists of the De- significantly reduced psychological dis- partment of Ophthalmology at the University tress and greater self-efficacy after the of Heidelberg and Dr. J. Jonas of the Depart- intervention. Brody et al. (2002) repeated ment of Ophthalmology at the University of Mannheim for supporting the comparison and extended their earlier findings by group sampling and Mrs. L. Jan Cargile for showing that their intervention program improving the language style of the article. resulted in significantly better mood and
©2006 AFB, All Rights Reserved Journal of Visual Impairment & Blindness, September 2006 533 functional ability in the recipients of the clinic’s treatment program. The major rea- intervention than in a control group. The son for such a short intervention program positive effects also held six months after was, in addition to cost-effectiveness, to the program ended (Brody, Roch-Levecq, reduce the transportation burden on at- Thomas, Kaplan, & Brown, 2005). The tendees (if they could still travel indepen- findings of Dahlin-Ivanoff (2000); Dah- dently) or to their relatives and friends lin-Ivanoff, Sonn, and Svensson (2002); (if they could no longer travel indepen- and Eklund, Sonn, and Dahlin-Ivanoff dently). In our earlier study (Birk et al., (2004) underscored the short- and long- 2004), a substantial number of patients term effectiveness of such interventions refused to participate in the five-session in improving or maintaining perceived group because of the length of the inter- security in daily activities, compared to vention and related logistical problems. usual care programs. The second goal was to follow an “emo- Birk et al. (2004) introduced a group tion-focused” approach in one line of in- intervention similar to the one suggested tervention and a “problem-focused” ap- by Brody et al. (2002) and Dahlin-Ivanoff proach in another. The major impetus for (2000), with even more emphasis on the this two-pronged approach was the clas- principles of cognitive-behavioral ther- sic distinction between emotion-focused apy (Rybarzcyk, DeMarco, DeLaCruz, versus problem-focused (or “cognitive”) Lapidos, & Fortner, 2001). For example, coping in research on stress and coping progressive muscle relaxation, a clas- (Filipp, 1999; Folkman & Moskowitz, sic means of reducing stress, was paired 2004; Lazarus, 1991). Only a few studies with training elements aimed at learning have followed this distinction, and there is how negative thoughts can trigger nega- empirical evidence that both coping modes tive emotions. Training for problem-solv- are important means of psychosocial ad- ing skills was a second major part of the justment for older adults who are visu- program. The intervention was based on ally impaired (Wahl, 1997). Against this five group sessions distributed over five research background, the main purpose weeks. A pilot evaluation study, also re- of our emotion-focused approach was to ported in Birk et al. (2004), provided be- further emotion-focused coping, and the ginning evidence that this program was major purpose of our problem-focused able to help participants improve their approach was to develop solutions for the coping strategies to deal more success- behavioral consequences of AMD in daily fully with vision loss in daily life and to life and by this means, cognitive cop- reduce their depressive mood. ing efforts (a more in-depth description The study presented here—continuing of our training program is presented in the line of research conducted by Birk et the Intervention program section). Since al. (2004)—was driven by three related we wanted to explore the differential ef- goals. The first goal was to conduct a pilot fectiveness of major elements of most evaluation of a short psychosocial group psychosocial intervention programs and intervention, which was limited to three thought that a three-session intervention sessions of two to three hours each over program would require us to concentrate three weeks and offered as part of an eye on one or the other intervention strategy,
534 Journal of Visual Impairment & Blindness, September 2006 ©2006 AFB, All Rights Reserved we decided not to use a combined strategy should be echoed in measures, such as of both coping modes in one program. Adaptation to Vision Loss (Horowitz & Our third goal was to explore the long- Reinhardt, 1998). We did not extend these term effects of the intervention, and to- hypotheses to the two-month follow-up ward that end, we included a postinter- assessment because there were reasons vention follow-up measure two months for and against the expectation that posi- after the study was completed. On the one tive effects would be preserved. hand, the expected short-term gains in the respective outcome measures achieved by Method both intervention programs could have RESEARCH DESIGN AND SAMPLE been maintained in the longer term, thus The research design was a pretest–posttest confirming what other studies have found standardized assessment of two interven- on the basis of more extensive interven- tion groups and a group without treatment. tion programs (Brody et al., 2005; Eklund All the participants who were in the treat- et al., 2004). On the other hand, a three- ment group were outpatients at the Depart- session training program may have been ment of Ophthalmology at the University insufficient to perpetuate the possible of Heidelberg, Germany, where the inter- short-term gains over several months. If vention programs were conducted. All the an intervention that is too short leaves too patients fulfilled the inclusion criterion of many unresolved issues, it may result in a diagnosis of AMD by the ophthalmolo- either the loss of gains from training or gists who were involved in the study; their more detrimental effects, such as unful- remaining visual acuity in the better eye filled hopes, which may eventually lead to had to be less than 20/50, representing a frustration and disappointment. substantial loss in day-to-day functioning With this backdrop, we formulated the and reading ability. In addition, they were following hypotheses. First, we hypoth- all older than age 60 and were living in esized that the different interventions private households. Patients with severe would lead to differential outcomes. In terminal illnesses, major hearing loss (not line with a classic insight of research on corrected or correctable by a hearing aid), training—that effects can be found mainly and major cognitive impairment, as doc- in the performance aspects of a training umented in their medical files, were ex- procedure (see Baltes & Willis, 1982)— cluded from the study. The sampling goal we expected that gains that were due to was of at least 20 patients in each treat- the emotion-focused approach should be ment group, to allow for the detection of detected predominantly as a decrease in at least “medium” effects at the .05 level negative emotion-related target concepts, of significance with a test power of 80% such as depression, and gains that were (Bortz & Döring, 1995; Cohen, 1988). due to the problem-focused approach A description of the participants is pre- would be manifest in the perceived ability sented in Table 1. Participants with lower to deal better with problems of daily liv- levels of education were represented more ing. Second, we expected a gain in general frequently in both intervention groups, adjustment from both the emotion-focused married participants were less frequent and the problem-focused approaches that in the comparison group, and those with
©2006 AFB, All Rights Reserved Journal of Visual Impairment & Blindness, September 2006 535 Table 1 Description of the sample at the preassessment. Emotion-focused Problem-focused Comparison Variable (at premeasurement) group (n = 23) group (n = 22) group (n = 22) Mean age (in years; SD, range in parentheses) 76.5 76.6 77.3 (6.8, 65–92) (7.1, 61–88) (6.4, 64–84) Gender: female (percent) 90 68 77 Education: Elementary school only (percent) 39 50 59 Civil status: Married (percent) 52 64 27 Duration of vision loss: More than one year (percent) 43 29 48 a long (more than one year) duration of ceived detailed information on the study’s vision loss were less frequent in the prob- purpose and procedures. lem-focused group. These differences did Of the 82 persons (58 from the inter- not, however, reveal any consistent ten- vention groups and 24 from the compari- dency toward a positive or negative selec- son group) who agreed to participate in tion for any group. the study, some did not show up at the To attain the sampling goal, a total of training site, some did not attend the full 76 patients with AMD were asked to par- set of three psychosocial training ses- ticipate in the treatment groups. Of the sions, and others could not be convinced 76, 58 agreed to participate and signed a to participate in the postassessment; thus, written informed-consent form after they a total of 15 individuals dropped out, 13 received detailed information on the pur- who were originally assigned to the in- pose and procedures of the study. These tervention groups and 2 who were origi- patients were randomly assigned to one nally assigned to the comparison group. kind of intervention (emotion focused Regarding the differences between the 15 versus problem focused). dropouts and the 67 pre–poststudy partic- The nontreatment group, which also ipants (23 in the emotion-focused group, fulfilled all the relevant inclusion crite- 22 in the problem-focused group, and 22 ria described earlier, was selected from in the comparison group), the overall psy- a list of outpatients with AMD that was chosocial adaptation of the participants provided by the eye clinic of the Univer- tended to be better than that of the drop- sity of Mannheim, Germany. We recruited outs, a problem that is often seen in in- the nontreatment group this way because tervention research (Schulz, Maddox, & the study’s resources did not allow for a Lawton, 1998). waiting-list control group. Because of this As expected, the sample sizes further limitation and the concomitant limitation decreased between the end of the study of an incomplete randomized assignment and the two-month follow-up. That is, to all the groups from the same population the emotion-focused group was reduced of patients, we use the term comparison from 23 to 21 participants, the problem- group, rather than control group. Of the focused group was reduced from 22 to 17 35 patients who were asked to participate participants, and the comparison group in the comparison group, 24 gave their was reduced from 22 to 16 participants. written informed consent after they re- No statistically significant differences
536 Journal of Visual Impairment & Blindness, September 2006 ©2006 AFB, All Rights Reserved with respect to the sociostructural and The primary goal of the emotion-fo- health-related variables or to depression cused intervention was to help the par- and adaptation to vision loss were found ticipants learn to deal with negative and between the 54 who remained in the study cumbersome emotions related to the and the 13 who did not participate in the day-to-day experience of loss caused by follow-up. AMD by talking about them in a group context. The participants were encour- THE INTERVENTION PROGRAM aged to do so by the creation of a warm The basis of the three-session psychoso- group atmosphere and the stimulation of cial group intervention was the program emotional expression by a pair of group developed by Birk et al. (2004), which trainers. In addition, a practically framed was designed for five group sessions “emotion change theory” was offered to across five weeks. In line with the empiri- communicate the message that negative cal intervention research on older adults and positive emotions are strongly trig- who are visually impaired (Birk et al., gered by cognitive beliefs and situational 2004; Brody et al., 2002; Dahlin-Ivanoff, evaluations (such as “My life is worth- 2000), one fundamental assumption was less now with such vision loss”) and that that a group approach is helpful to pro- changing these cognitions can lead to bet- mote positive change in elderly persons ter emotional adaptation. Moreover, all with AMD (see also Harshbarger, 1980). kinds of positive experiences in the lives Group settings tend to stimulate, for ex- of the participants were highlighted, and ample, vicarious learning experiences, training was offered, so the participants and simply sharing similar experiences could actively seek and create everyday related to vision loss with others can be a life situations that evoke a maximum of great relief. Another fundamental assump- positive emotions. The participants were tion was that three sessions offered across given homework to help carry over the three weeks may be an intervention that is principles of “emotion change theory” to intense enough to have a positive impact their everyday lives. on older persons with AMD, given that a The primary goal of the problem-fo- focused approach on either negative emo- cused intervention was for the participants tions related to the experience of AMD or to deal with all kinds of daily problems on coping with everyday problems related caused by AMD in a strongly “I can make to AMD is followed. Still another, third, it” manner. Emphasis was placed on dis- fundamental assumption, in line with the cussing common problems of daily liv- literature on both general group training ing, which was again encouraged by the and group therapy (see, for example, Ry- creation of a warm group atmosphere and barczyk et al., 2001), as well as evidence the stimulation of such emotional reports from previous intervention programs with by the group trainers. In addition, a prac- persons with AMD (Birk et al., 2004; tically framed “problem change theory” Brody et al., 2002; Dahlin-Ivanoff, 2000), was offered to communicate the message was that both strategies have a unique po- that labeling problems as unsolvable is tential to improve the psychosocial situa- frequently unjustified and an overgeneral- tion of persons with AMD. ization (for instance, “I can no longer han-
©2006 AFB, All Rights Reserved Journal of Visual Impairment & Blindness, September 2006 537 dle my life”), whereas a detailed problem Problem Orientation from the Freiburger analysis and the implementation of achiev- Fragebogen zur Krankheitsbewältigung able goals can lead to better adaptation. (Frieburg Inventory on Coping with Ill- Multiple strategies to find such solutions, ness), a standard German psychodiagnos- albeit by unusual means, such as changing tic instrument to assess styles of coping one’s home environment, using one’s other with illness (Muthny, 1989). This five- senses, or changing the “normal” routine item measure addresses illness-related of activities, were explored. The goal was behaviors, such as seeking information on to work successfully on at least one real diseases and treatments or making plans and meaningful problem across the three to cope proactively with illnesses. Each sessions. Again, homework was given to item is rated on 5-point Likert-type scale, encourage the translation of the principles from 1 (“not at all”) to 5 (“very strong”), of problem change theory into the partici- leading to a theoretical range of 1 to 25 pants’ day-to-day lives. points. Higher scores indicate a higher Similar to the precursor study (Birk et active problem orientation. The internal al., 2004), a clinical setting—the Depart- consistency of the Active Problem Ori- ment of Ophthalmology of the University entation subscale reached a Cronbach’s of Heidelberg—was chosen as the site of alpha of .75 in the present study for the both intervention groups. Two group train- entire sample of 67 at the preassessment. ers with a background in clinical psychol- With respect to adjustment at large, we ogy ran each group because we expected applied a German version of the Adapta- that a dense psychosocial intervention tion to Vision Loss Scale (AVL; Horowitz across three sessions would likely profit & Reinhardt, 1998) to assess the extent to from such teamwork. We found that the which a person accepts vision loss in a re- optimal size of each group ranged from a alistic manner. A sample item is “Because minimum of three to a maximum of six of my vision loss, I feel that I can never persons. really do things for myself.” We used a shortened version of the original scale pro- OUTCOME MEASURES posed by Horowitz and Reinhardt (2001, With respect to emotional adaptation, we personal communication) consisting of 14 used the 15-item short version of the Ge- items to be answered on a 4-point scale, riatric Depression Scale (GDS; Sheik & from 0 (“strongly agree”) to 3 (“strongly Yesavage, 1986) with a required yes-or- disagree”), leading to a theoretical range no answer on each item and higher scale of between 0 and 42 points, with higher scores indicating more severe depressive scores indicating higher adaptation. The states. The theoretical range is thus be- Cronbach’s alpha of this shortened ver- tween 0 and 15 points. Internal consis- sion of the AVL reached .74 in the pres- tency of the GDS typically is generally ent study, while Horowitz and Reinhardt high and reached a Cronbach’s alpha of (1998) reported a Cronbach’s alpha of .84 .82 in the present study for the entire sam- for the original version consisting of 33 ple of 67 at the preassessment. items. To address the participants’ problem All the assessments in the study were orientation, we used the subscale Active performed as telephone interviews by
538 Journal of Visual Impairment & Blindness, September 2006 ©2006 AFB, All Rights Reserved trained research assistants who were not tive outcome level at T1 controlled simul- informed about the research status of taneously as a covariate (ANCOVA). AN- those they interviewed. The mean period COVAs were run for T1–T2 comparisons, between the pre- and postassessment was as well as for the comparison of T1 with 39.5 days (SD = 12.8), and the mean pe- the two-month postassessment (Time 3, riod between postassessment and the or T3). In addition to conventional signif- two-month follow-up was 58.2 days (SD icance testing, we calculated effect sizes = 17.8). The mean duration of the assess- based on Cohen’s (1988, p. 407) recom- ment was approximately 20 minutes. mendations for ANOVA designs and ex- pressed them in percentages. A unique DATA ANALYSIS determination value of at least 2% of the Because the generation of a separate com- overall outcome variance is regarded as parison group was not the result of ran- the threshold for a small effect, 13% for domization and those who dropped out a medium effect, and 26% for a large ef- had been assigned to a treatment condi- fect. tion, we expected to find group differ- ences at Time 1 (T1—preassessment) Results with possible consequences for Time 2 Table 2 depicts the findings of all three (T2—postassessment). Therefore, we con- outcome measures. Means and standard ducted analyses of variance (ANOVAs) deviations are shown at T1 and T2. Table based on the change scores for each of the 2 also gives the mean difference scores of three outcome measures, with the respec- T1 and T2. It should be noted that these
Table 2 T1–T2 assessments regarding outcome measures. M (SD in parentheses) Difference Effect size Outcome measure, by groupa T1 T2 T2-T1b p-valuesc (percent)d
Depression p = .047 2.7 EmG 3.5 (2.8) 2.9 (2.2) –0.55 PrG 4.1 (3.8) 4.1 (4.0) 0.15 CG 3.7 (3.1) 3.6 (3.2) –0.06 Active problem orientation p = .000 15.9 EmG 15.1 (4.6) 13.7 (4.5) –0.39 PrG 12.4 (4.9) 14.6 (5.4) 2.14 CG 10.0 (4.5) 9.5 (3.5) –1.56 Adaptation to vision loss p = .002 11.1 EmG 25.9 (6.9) 25.8 (6.8) 0.18 PrG 22.4 (6.1) 26.4 (8.3) 3.51 CG 25.6 (6.6) 24.7 (6.1) –0.64 aEmG = emotion-focused group (n = 23), PrG = problem-focused group (n = 22), and CG = comparison group (n = 22). b Difference scores were corrected for potential differences of the respective outcome variables at the T1 as- sessment. cANCOVA of intervention group effects on T1–T2 differences, controlled for T1-levels. dEffect size calculation for the ANCOVA designs according to Cohen (1988, p. 407); 2% = small effect, 13% = medium effect, and 26% = large effect. * p <. 05, ** p < .01.
©2006 AFB, All Rights Reserved Journal of Visual Impairment & Blindness, September 2006 539 difference scores are estimations that ac- The expected increase in both inter- count for different group levels at the vention groups in adaptation to vision preassessment. Furthermore, the result of loss was only partially confirmed. A sig- the ANCOVA in terms of the statistical nificant increase was observed only in the significance of the unique design-group- problem-focused group, with an effect effect (after the T1 level was statistically size indicating a small effect, F(2,62) = controlled as a covariate), as well as the 5.72, p = .002 (11.1%), not far from the respective effect sizes, are reported. threshold for a medium effect (13%). As can be seen, the depression scores With regard to the comparison of the were, as expected, lower at T2, particu- preassessment status of the groups with larly in the emotion-focused group. In ad- their two-month follow-up status, a re- dition, the mean change scores were the markable effect appeared, particularly in highest for this group. Although this ef- the case of depression. As can be seen in fect was statistically significant, F(2,63) Table 3, depression increased in the prob- = 2.81, p = .047, the respective effect lem-focused group between T1 and T3, size revealed only a small effect (2.7%). with a medium-sized overall interven- It should be noted here that the depres- tion-group effect, F(2,50) = 3.52, p = .037 sion level was already low at T1 in both (12.3%). In addition, active problem ori- intervention groups, making it difficult entation decreased somewhat in the emo- to reduce further the participants’ average tion-focused group, but more strongly depression level. Taking the suggested in the problem-focused group and in the cutoff of 5 as an indication of clinically comparison group. However, this change relevant depression in the GDS (Sheik & was not significant and was small in Yesavage, 1986), we found that three par- terms of effect size, F(2,49) = 0.93, p = ticipants in the emotion-focused group, .403 (3.7%). Finally, change with respect compared to two participants in the prob- to adaptation to vision loss was no longer lem-focused group, switched from over observable; that is, no statistical signifi- to under this threshold between T1 and cance appeared, and the effect size was T2. In the comparison group, this was the below the 2% threshold (0.9%) indicating case for one participant. In sum, the effect no effect, F(2,49) = .22, p = .799. in terms of depression was in the theoreti- cally expected direction, but it was rela- Discussion tively weak. A body of research has demonstrated that In accordance with our hypotheses, the the psychosocial needs of elderly per- participants’ active problem orientation sons who are visually impaired, particu- increased, particularly in the problem- larly those with AMD, are substantial (see focused group. Also, the effect size Brody et al., 2001; Burmedi et al., 2002; pointed to a medium effect in this case, Horowitz & Reinhardt, 2000; Wahl et al., F(2,62) = 10.08, p = .000 (15.9%) That 2004). These needs are, however, largely is, the effect observed with respect to ac- unmet in ophthalmological treatment re- tive problem solving was substantial even gimes. The major goal of this study was to after the differences in this variable were expand previous psychosocial interven- controlled at T1. tion programs for persons with AMD by
540 Journal of Visual Impairment & Blindness, September 2006 ©2006 AFB, All Rights Reserved Table 3 T1–T3 (two-month follow-up) assessment regarding the outcome measures. M (SD in parentheses) Outcome measure, Difference Effect size by groupa T1 T3 T3–T1 p-values (percent)
Depression .037 12.3 EmG 3.2 (2.4) 3.2 (2.0) –0.04 PrG 4.1 (3.6) 5.3 (4.4) 1.36 CG 3.2 (2.6) 2.9 (2.7) –0.33 Active problem orientation .403 3.7 EmG 15.3 (4.8) 13.5 (3.6) –0.46 PrG 14.1 (4.8) 11.6 (4.9) –1.98 CG 9.7 (4.9) 9.8 (4.3) –2.16 Adaptation to vision loss .799 0.9 EmG 25.7 (6.6) 26.4 (5.6) 0.78 PrG 22.9 (6.1) 24.2 (6.9) 0.40 CG 27.1 (5.9) 28.2 (8.1) 1.69 aEmG = emotion-focused group (n = 21), PrG = problem-focused group (n = 17), and CG = comparison group (n = 16); see the notes for Table 2 for additional explanations. testing the effects of a short psychosocial lem-focused approach of this study (Birk intervention based on only three group et al., 2004; Brody et al., 2002, 2005; sessions distributed across three weeks. Dahlin-Ivanoff, 2000; Dahlin-Ivanoff et The study provided some empirical al., 2002; Eklund et al., 2004). In sum, evidence for our hypotheses of the differ- our T1–T2 effects were generally weaker ential effectiveness of two major compo- than those reported in the other studies. nents that are typically included in such The major explanation for this finding is programs: A positive intervention ef- probably the lower dose of psychosocial fect (concerning an increase in an active intervention provided in only three ses- problem orientation) from the pre- to the sions in our study, compared to the 6–10 postassessment was observed only in the sessions in the other studies (Brody et al. problem-focused group, and a decrease, 2002; Dahlin-Ivanoff, 2000). although weak, in depression was ob- Additional findings of this study un- served only in the emotion-focused group. derline that there may also be substantial One possible reason for the small de- qualitative differences in short versus lon- crease in depression may be that the aver- ger psychosocial group interventions. As age depression status of both intervention we found, not only did the positive effects groups at T1 was already low, which may of active problem orientation and adap- have been a result of the observed positive tation to vision loss disappear from the selection effects. The expected overall pre- to the two-month follow-up assess- increase in adaptation to vision loss was ment, but depression increased substan- found only in the problem-focused group. tially in the problem-focused intervention Thus, our findings coincide, in general, group. Of course, these findings need to with the positive effects reported in other be interpreted with caution because of the studies with regard to self-management small samples. It seems, however, that the programs, which were similar to the prob- problem-focused intervention, with its “I
©2006 AFB, All Rights Reserved Journal of Visual Impairment & Blindness, September 2006 541 can make it” impetus, may have raised least six group training sessions. We also the hope that it is possible to solve one’s believe, after the practical experiences of psychosocial problems related to AMD in our study, as well as the results of other a short period of time. But if this initial studies (such as Brody et al., 2002), that stimulation is not continuously supported it is economically feasible to use only one after the intervention sessions, frustration trainer per group, rather than the two that and disappointment may result. It is im- were used in our study. portant to note that long-term evaluations, In conclusion, there is still a great such as Brody et al.’s (2005) six-month need for additional outcome studies (both evaluation, have found promising effects short- and long-term) of psychosocial in the longer term, which supports the interventions with older adults who are need to have at least six sessions to make visually impaired that include measures it more likely that the positive effects will of cost-effectiveness, to improve the evi- be sustained. dence for such investments. On a more The combined interpretation of the practical level, psychosocial interven- T1–T2 and T1–T3 findings leads us to tions provide an important addition to conclude that short psychosocial inter- traditional low vision rehabilitation pro- ventions programs for persons with AMD grams and may even enhance their effec- are insufficient. Instead, on the basis of tiveness. earlier intervention research (such as Birk et al., 2004; Brody et al., 2002; Dahlin- References Ivanoff, 2000; Eklund et al., 2004), at Baltes, P. B., & Willis, S. L. (1982). Plasticity least six group sessions seem necessary and enhancement of intellectual function- to provide sustainable gains in psycho- ing in old age. In F. I. M. Craik & S. Tre- social outcomes. Furthermore, a mix of hub (Eds.), Aging and cognitive processes psychosocial elements that address both (pp. 353–389). New York: Plenum Press. behavioral and emotion-oriented strate- Birk, T., Hickl, S., Wahl, H.-W., Miller, D., Kämmerer, A., Holz, F., Becker, S., & gies, such as the one suggested by Birk et Völcker, H. E. (2004). Development and al. (2004), may be the most effective in pilot evaluation of a psychosocial interven- eliciting problem-solving as well as emo- tion program for patients with age-related tion-related improvement in the quality of macular degeneration. Gerontologist, 44, life of persons with AMD. 836–843. The limitations of our study in terms Bortz, J., & Döring, N. (1995). Forschungs- methoden und evaluation [Research meth- of the rigor of the design and the sample ods and evaluation]. Berlin: Springer. sizes are obvious. In particular, it was not Brody, B. L., Gamst, A. C., Williams, R. A., possible to assign participants to treat- Smith, A. R., Lau, P. W., Dolnak, D., Ra- ment and control groups in a strictly ran- paport, M. H., & Kaplan, R. M. (2001). dom manner, and thus caution is neces- Depression, visual acuity, comorbidity, and sary regarding the generalizability of our disability associated with age-related mac- ular degeneration. Ophthalmology, 108, findings to all persons with AMD. How- 1893–1901. ever, we believe that our study provides Brody, B. L., Roch-Levecq, A.-C., Gamst, A. additional evidence that can be used to C., Maclean, K., Kaplan, R. M., & Brown, plan future intervention research with at S. I. (2002). Self-management of age-
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