depression is a common mental health problem among people with visual impairment ( burmedi , becker , heyl , wahl , & 
 himmelsbach , 2002 ) . a study in britain showed that people with visual impairment 
 had a higher prevalence of depression compared with people with good vision , because people 
 with visual impairment were more likely to experience problems with functioning , which in 
 turn lead to depression ( j. r. evans , 
 fletcher , & wormald , 2007 ) . in managing depression with psychological therapy , cognitive - behavioral therapy ( cbt ) is 
 known to be effective in a wide age range of patients around the world , including late 
 adulthood ( serfaty et al . , 2009 ) . specifically , short group cbt has been shown to reduce depressive symptoms in depressed 
 indonesian older adults ( utoyo et al . , 
 2013 ) . however , in cases involving older adults with physical disabilities , such as 
 visual impairment , it was recommended that aspects of the therapy should be modified to suit 
 the impairment ( c. evans , 2007 ) . this case report aims to report on the results of modifying a standardized cbt for 
 depression to suit a severe visual impairment condition suffered by an indonesian older 
 adult . a 77-year - old indonesian woman who was a retired kindergarten teacher with retinal 
 detachment ( 75% blindness ) was diagnosed with major depressive disorder based on 
 diagnostic and statistical manual of mental disorders ( 4th ed . , text 
 rev . ; dsm - iv - tr ; american psychiatric association , 2000 ) criteria . she had no mental health 
 treatment history and was currently not in any kind of non - pharmacological intervention , 
 either exercise or psychosocial . her change in personality and habit motivated her husband 
 to seek professional help for her and contacted a psychologist to examine her at home . the 
 patient lived with her husband in a house in depok , west java , indonesia . her retinal 
 detachment condition started at 2009 due to a head trauma , complicated with previous 
 cataract surgery and severe anemia . since then , her visual condition worsens through time . 
 at the time of the examination , which was in 2012 according to her ophthalmologist , managing her visual 
 condition required a surgical procedure that was very risky for her age . therefore , her ophthalmologist only prescribed her 
 with vitamins to manage her eye condition . separately , she took medicine for her anemia as 
 prescribed by her internist . other than her visual condition and anemia , she did not report 
 to have other medical or psychiatric condition . her husband complained that her partial sight condition changed 
 her into a different person : she lost self - confidence and refrained from going outside . she , 
 however , had a different complaint : she felt frustrated due to her failure in doing daily 
 activities ( such as cooking and preparing food ) . this study was a clinical case , approved and conducted under supervision of a senior 
 clinical psychologist and lecturer from the faculty of psychology , university of indonesia , 
 depok , indonesia . written informed consent from the patient and her husband were obtained in 
 the first meeting of initial assessment . the main measurement tools for this study were the depression assessments : indonesian 
 version of beck depression inventory ( bdi ; suwantara , lubis , & rusli , 2005 ) and indonesian 
 back - translated geriatric depression scale ( gds ; yesavage et al . , 1983 ) . there were three measurement 
 points : baseline , mid - test at 3rd week of the treatment , and posttest at 1 week after the 
 end of treatment ( 5 weeks from baseline ) . in addition , mini mental status examination ( mmse ; folstein , folstein , & mchugh , 1975 ) was conducted 
 as part of the initial assessment to assess for possible cognitive impairment that may 
 prevent her to follow the therapy . following depression diagnosis of the patient obtained from the pre - test result , an 
 evidence - based psychological treatment , cbt , is chosen . cbt has been shown to be effective 
 in treating depression for older adults , especially because the aim of cbt is to help the 
 patient identify , challenge , and alter maladaptive thinking ( scogin , welsh , hanson , stump , & coates , 
 2005 ) . the treatment was based on a treatment manual that has been previously shown to be able to 
 reduce depressive symptoms ( utoyo et 
 al . , 2013 ) . it consists of eight sessions of 120 min each , and two sessions were 
 given per week ( every 3 to 4 days ) . the content of the therapy were psychoeducation about 
 depression and cbt itself , activity scheduling and monitoring , relaxation techniques , 
 cognitive restructuring , and problem - solving techniques . the treatment was modified to suit the patients partial sight condition by recording all 
 the materials into a cd . this approach was taken because the patient was known to operate a 
 cd player regularly to listen to music . this modification of the treatment manual ( utoyo et al . , 2013 ) was done under 
 all authors permission . also , all necessary adaptation to be used in the present study 
 setting had been discussed . other concurrent interventions were allowed , but the patient did 
 not report engaging in any other interventions . for the written section of the treatment 
 (  homework ,  in cbt terminology ) , the patient did it with her husband s or the therapist s 
 assistance twice every week . the homework included , for example , regular breathing 
 relaxation and progressive muscle relaxation exercise , daily mood monitoring and activity 
 planning , as well as cognitive restructuring with her husband s or therapist s 
 assistance . although reduced memory function 
 was found , the condition can still be categorized as a result of normal aging process , 
 according to the mmse norms for the patient s age group . due to the absence of significant 
 cognitive impairment , no contra - indication for using cbt therefore , the patient 
 was deemed to be suitable to receive cbt for depression . the depression level of the patient gradually declined across three measurement points for 
 the bdi and gds ( figure 1 ) . at 
 baseline , the patient s depressive symptoms scores were categorized as severe depression 
 ( bdi , 25 ) and moderate depression ( gds , 20 ) using their respective norms . then , at posttest , 
 the patient s bdi score was reduced to mild or moderate depression ( bdi , 14 ) , and her gds 
 score was reduced to no depression ( gds , 10 ) . furthermore , at posttest , the patient reported 
 that she was sleeping normally , no longer felt depressed , regained her self - confidence , 
 regained her interest to be active , and regained her appetite . furthermore , she was also no 
 longer experiencing ulcer and itchiness ( psychosomatic symptoms ) , which she previously 
 had . this case report showed that modification of a conventional evidence - based psychological 
 treatment to suit the patient s visual impairment condition can reduce depressive symptom . 
 with this result in mind , it is suggested that modifying a currently available 
 evidence - based treatment to suit patient s condition , rather than inventing a new one , is a 
 reasonable approach . in addition , this case report provides an illustration of depressive symptoms on visually 
 impaired depressed indonesian older adult . the patient experienced conventional symptoms of 
 depression commonly found in patients in western cultural context , such as feeling 
 depressed , having difficulty sleeping , losing appetite , and losing self - confidence ( e.g. , 
 rush , carmody , & reimitz , 
 2000 ; rush et al . , 1986 ) . this case report runs counter to the notion that depression is a uniquely western phenomenon 
 ( jadhav , 1996 ) , although there 
 is a slight difference of symptom presentation in common depressive patients in western 
 cultural context . the patient was primarily concerned about her ulcer and sleep difficulty 
 ( psychosomatic symptom ) . this similar emphasis on somatic symptom is also observed on 
 chinese depressive patients in china , although , interestingly , such emphasis is not found in 
 white americans or chinese in the united states ( yen , robins , & lin , 2000 ) . limitations , however , have to be taken into account in interpreting the findings . 
 assessments and therapy furthermore , 
 this setting preserves external validity as it mimics everyday psychologist practice in 
 indonesia to sum up , this case report showed that the patient with visual impairment experienced 
 functioning problem , which leads to depression . ( 2007 ) , who found 
 that people with visual impairment have functioning problem and higher depressive symptoms . 
 therefore , screening and treating depression in people with visual impairment is important . 
 in the absence of available appropriate psychological treatment , this case report showed 
 that it is possible to modify current evidence - based treatment to suit the need of the 
 patient . this is probably no longer needed , once the planned trial on psychological 
 treatment for depression on people with visual impairment is successful ( margrain et al . , 2012 ) .