The development of posttraumatic stress disorder in individuals with visual impairment: a systematic search and review

Authors: van der Ham AJ, van der Aa HP, Brunes A, Heir T, de Vries R, van Rens GH, et al.

Geographical coverage: The United Kingdom, Norway, Israel, Lebanon, New Zealand, Australia and Canada.

Sector: Burden of disease

Sub-sector: Epidemiology

Equity focus: None

Study population: People with visual impairment

Review type: Other review

Quantitative synthesis method: Narrative review

Qualitative synthesis method: Not applicable

Background: Posttraumatic stress disorder (PTSD) is a mental health problem with a negative impact on quality of life. Despite the considerable research on PTSD in various types of chronic conditions, limited attention has been given to whether individuals with visual impairment are at high risk of trauma and PTSD. According to diagnostic criteria for PTSD, vision loss in itself is generally not considered as a traumatic event. PTSD in people with visual impairment is thought to be more likely to be the result of traumatic events, which are not directly related, or are only indirectly related to, visual impairment.

Objectives: The purpose of this systematic review was to describe and discuss the literature on the development of PTSD in people with visual impairment.

Main findings:

Evidence included in this review suggests some unique experiences and challenges for people who are visually impaired, in relation to the development of PTSD. PTSD was prevalent in this population, and prevalence rates ranged from 4% to 50%.

13 articles were included in the review. All 13 articles involved empirical research. Five had a quantitative design, four a qualitative design, three presented case studies and one applied mixed-methods. Four originated from the United Kingdom, three from Norway and two from Israel. The remaining four articles were from Lebanon, New Zealand, Australia and Canada. Of the 13 articles, seven included an assessment of PTSD, while six focused on traumatic events in relation to PTSD-related complaint without an assessment of PTSD. The review found that visual impairment was often vaguely described, and PTSD diagnoses were typically based on DSM criteria. Most articles didn’t formally define traumatic events, with a third focusing on war-related incidents and others on various traumas. The quality of the studies varied, with none rated as ‘good’ across all assessment items. Five were rated as ‘sufficient’ or ‘good’ overall, but others scored ‘insufficient’ or ‘unclear’ on at least two items. Key issues included a lack of PTSD assessment or focus on a specific trauma type (relevance), insufficient methodological and ethical details (reliability), potential bias and strong conclusions (validity), and lack of attention to study implications (applicability).

Findings are presented along three main themes: (1) posttraumatic stress disorder; (2) traumatic events; and (3) impact of traumatic events. People with visual impairments may be at higher risk of being exposed to certain potentially traumatic events (due to a vulnerability for experiencing such serious events as accidents or sexual abuse). Increased dependency, isolation and reduced mobility may also make such events more likely. Studies estimate that between 4-50% of individuals with VI have experienced PTSD, although estimates highly population-dependent. Limited/restricted access to situational information during events may contribute to the stressfulness of the experience. Furthermore, visual impairment may shape the impact of traumatic events.

Authors note that future research may focus on gaining insight into the extent and burden of PTSD, and exploring help-seeking behaviour and treatment needs among those with visual impairment and PTSD.

Methodology:

Inclusion criteria consisted of articles were included if they either directly addressed PTSD in people with visual impairment, or if they addressed PTSD indirectly by focusing on traumatic events in relation to PTSD-related complaints. A search was performed without date, language or publication status restrictions.

A literature search in PubMed, EMBASE, PsycInfo and Web of Science was performed up to 15 November 2019 in collaboration with a medical information specialist. Additional search strategies included hand searches of references of retrieved papers and free-text hand searches in Google Scholar. Relevant research in grey literature was included. The search was performed by the first and last authors. The third and fourth authors peer reviewed the articles selected for inclusion to determine whether important articles were missed.

Two authors performed a quality assessment according to criteria of the Public Health Ontario Meta-tool for Quality Appraisal for Public Health Evidence. The MetaQAT assessment form includes questions on relevancy, reliability, validity, and applicability.

Thematic content analysis of the extracted data was carried out in order to identify main themes and subthemes (although there is little description of what this involved in practice).

Applicability/external validity: Validity not discussed by study authors.

Geographic focus: Authors state that all included studies were undertaken in high income countries, and so not necessarily applicable to other contexts.

Summary of quality assessment:

The review used very robust methods for identifying, including and appraising studies, with the search not being limited by language or publication status and at least two authors undertaking all stages of the process. While the methods for analysis of the data appear to be generally robust, the precise approach to thematic analysis used is unclear and, as the authors acknowledge themselves, some of the evidence included in the review was of a relatively low quality. For these reasons, a medium confidence was attributed to the findings of this review.