Mental health difficulties faced by deafblind people

How does it feel to lose your sight and hearing as an adult? We tend to focus on the physical effects, no longer being able to read, missing the doorbell, but are we averting our eyes from the emotional effects, which can be just as hard to cope with? Sarah Butler talks to deafblind people, and the professionals they turn to, when the going gets tough.

Mark's knuckles show white through the pale skin of his hands. He clutches his head as he tells me he doesn't know how bad his hearing will get. But when he begins to describe how he feels, he runs out of words. He has no need of them, his expressive, pianist's hands are all too eloquent and his distress clear to see.

Many of us go through hard or confusing times, and sometimes we struggle to deal with them. Mostly we pick ourselves up again after a while and find that we're back to normal. But sometimes we'll experience mental distress which our usual ways of coping just can't put aside. If this goes on too long, we may become ill, whether we are deafblind or not.

Why do we become mentally ill?

There are lots of factors which can lead anyone to become mentally ill. Our environment and the people around us, our psychological makeup, and the physical state of our brain all make a difference to the way we deal with difficulties in our lives. Much is to do with how well we adapt to change. If someone close to us dies, we grieve, of course, but if we have just moved town, are doing a stressful job, and are prone to depression, we may find it harder to deal with than another person who feels secure and has a close-knit circle of friends to talk to when things go wrong.

Most often, a person becomes mentally ill when several factors come together. Often it's something seemingly quite small that finally tips the balance, the proverbial straw that breaks the camel's back. For instance, one woman who has been losing her sight and hearing for a while had a crisis when she found that she could no longer do the ironing. It marked the time when she could no longer look after her household on her own, the moment when she lost her independence.

Does deafblindness make us more vulnerable?

If anyone can become mentally ill, is there anything about becoming deafblind that makes a person especially vulnerable? For a long time, it seemed not, figures gathered by counting how many deafblind people used mental health services seemed to show that they were in fact less likely to become ill. But it is becoming clear that, on the contrary, more deafblind people suffer mental illness than do other people. They are just less likely to come to the attention of professionals.

For most people, there's nothing intrinsic about deafblindness that leads directly to mental distress. It's not like catching an infection that has predictable symptoms in the body. Rather, it's the effects of deafblindness on daily life that tend to knock people off balance. If you can no longer read your bank statements, you will find it hard to keep a check on your money, yes. But you may also feel sad that someone else will have to do this task, even though you are perfectly capable of managing your money you may be frustrated and mourn your loss of control.

Everyone responds differently of course. A Canadian team working with deafblind people noted that many factors affect the social and psychological impact of deafblindness, including someone's age, the way they communicate, whether they are part of Deaf culture, the nature of their sensory loss, their level of education, their income, their social network, their work, their personality. Other people back this up. Some people who suffer sensory loss adapt to it, and overcome the difficulties they encounter. Others find this much harder, and may become mentally ill.

Sarah Bodsworth and Isabel Clare sent a questionnaire to deafblind adults last year about their mental health. Their interviewees identified five main issues: trauma, isolation, dependency, communication, and access to information.

These five effects of deafblindness led to alarming levels of mental distress. They often feed into each other, too: someone struggling to communicate is likely to become isolated. Anyone else who had undergone a different major loss, of a limb, or of a partner, for example, could turn to those closest to them for comfort, but a deafblind person for whom communication is a struggle may have to deal with their feelings quite alone. Communication problems also have wider implications for people's mental health, all too often a doctor who struggles to communicate with a deafblind person misses the early signs of mental illness, which go untreated and may turn into a far more serious problem.

The Canadian deafblind rehabilitation team found that people's overwhelming experience of becoming deafblind was one of loss:

'The loss is abundant: no longer being able to enjoy certain activities (reading the newspaper, listening to music), losing one's autonomy (driving one's car), no longer being able to stay busy at work, etc. Deaf blind people tell us that they feel out of synch with what is happening in their immediate environment and in the greater community. A person may then feel frustration, injustice, sorrow, a lower self-esteem, anxiety, etc. They must accommodate these emotions, manage them and find ways to constantly adapt to their new sensory condition.'

This constant need to adapt to changes in your sight and hearing is an enormously stressful feature of much acquired deafblindness. Conditions don't stand still. You may have found a balance, only for something new to happen, throwing you back into disarray.

Some events are particularly hard to cope with. For one person their greatest loss may be the day they hand over the keys to their car. For another it is the day they can no longer read a novel. Consultant psychiatrist Dr Margaret du Feu calls these 'significant thresholds'. They can be times of great inner conflict, between the desire to remain independent, and recognition that you need to ask for help.

A deafblind person's changing life affects those close to them too. Roles in a family can be up-ended, with a provider becoming the provided for, or the decision-maker taking a back seat. As communication becomes more difficult, the deafblind person may withdraw not only from wider society but also from the family, and everyone is affected by the resulting isolation. Margaret du Feu puts it eloquently: 'when somebody can't hear, it means in effect that those around them lose their own voices. They also find it hard to see the person they love in difficulties. The important thing is for communication to be as open as possible and for people, including the relatives, to be able to talk about how they feel, for example if a spouse needs a break then they should be able to say this.'

On the other hand, a very large number of deafblind people live alone. Many are older people, who make up the majority of those who are deafblind. Even without taking sensory loss into account, there is a far higher incidence of suicide in older people than there is in the rest of the population, and when you add in the effect of deafblindness, it is clear that many older people will find it hard to cope with their impairment. Ill health, the death of partners and friends, discrimination, poverty, all combine to make life difficult for many older people, who can easily begin to lose their independence and confidence.

It's worth noting that, while deafblindness can affect people's mental health, some people have a history of mental illness before they become deafblind. Their deafblindness may not make their mental health problem any worse or better, although the stress it can bring may spark off an episode of illness. And equally, deafblind people experience all the same stresses that can cause problems in anyone's life, divorce, bereavement, physical illness and if they become mentally ill, it is just as likely that these factors are the root of the problem rather than their sensory loss.

In what ways do people become mentally ill?

A deafblind person may respond in many ways to the challenges of their impairment. There is often shock or denial at diagnosis, which may be followed by distress, frustration, passivity or anger. There may be grief at the loss of the future which they had imagined for themselves, and at actual losses. And these responses may be repeated when their condition worsens, or their life changes again. Their responses are all entirely normal, and eventually most people adapt and move on. However some people's distress turns to depression and/or anxiety, which are probably the most common problems for which people need help.

What is depression?

It's not unusual to feel sad, or to grieve for something lost, but if these feelings become overwhelming they may turn into depression. The mental health charity Mind says that someone with depression may have symptoms including 'persistent low mood, negative thoughts, feeling empty and in despair, problems with eating and sleeping, low self-esteem, irritability, not being able to enjoy favourite activities, loss of libido, low energy, inability or non desire to communicate, thoughts of self-harm or suicide'.

If you, or someone you know, show some of these symptoms, you might find that you'll feel better if you seek some help. A mild depression may be helped by herbal remedies such as St John's Wort (but don't take it without checking with your GP first), or talking therapies such as counselling. Beyond this, your GP may prescribe anti-depressant drugs, or cognitive behavioural therapy (CBT), which helps you to think positively and to find ways of coping with problems.

If you, or someone you know, is thinking about self-harm or suicide, you can contact the Samaritans, go to your GP, or if things are really bad, go straight to your hospital's accident and emergency department.

What is anxiety?

Losing your sight and hearing can be frightening. On diagnosis you may be afraid of what is going to happen to your senses and of what the future holds. This may never go away completely, and can be awakened when your condition changes. Situations can be frightening too.

If you feel nervous, sweaty, lightheaded, have a rapid heartbeat and breathing, you have the signs of anxiety. We've all experienced them at some time. But if you feel like this for much of the time, and especially if you begin to feel anxious about being anxious and begin to develop phobias or obsessions, your anxiety has become a problem and you probably need some help to deal with it.

The best way to deal with anxiety is to find ways of controlling the symptoms. Possible ways of doing this include learning relaxation techniques, yoga, and cognitive behavioural therapy (CBT). Sometimes a doctor will prescribe tranquillisers, though as they are addictive this is not an ideal treatment.

Much of this information comes from Mind, who has excellent information sheets about anxiety and its treatment.

For a few people, the physical effects of deafblindness itself, rather than its social or psychological effects, can lead to serious distress. As they see and hear less and less, the world around them can become a confusing place. If what they see and hear is distorted or fractured, it may be hard for them to interpret it. They may feel as though they are hallucinating, and begin to lose the ability to tell apart reality and that which they imagine.

In this case, if someone is no longer communicating with other people, and so is not receiving feedback about what is going on, they may lose their ability to relate to the world around them. If they are given a means of communicating though, such as deafblind manual or block, they will often recover well.

Story 1

A lady in her 80s had very limited sight and hearing. She used a wheelchair and had fallen in her own home, and been admitted to a residential home. Care staff thought that the lady had dementia, and so wanted her moved from the home. Luckily her social worker for deaf people wasn't convinced, and called Liz Duncan in from Sense.

Shortly after Liz arrived, a member of staff came in and announced that it was hairdresser day and began to wheel the lady off down the corridor. As the floor surface changed, the lady said, quite clearly 'I don't want my hair doing'. Even though she had not heard what the carer said, she had worked out where they were going out from the feel of the route her chair was taking. She certainly wasn't suffering from dementia; she was very stressed by her situation, as she had no idea where she was or why, and was using every ounce of energy to make sense of what was going on around her. The result was that Liz trained her and the staff in ways to communicate, and she was able to stay.

Quite a few deafblind people see visual illusions, or hear sounds that are not there. These can be very convincing, they may hear people speaking in the next room, or see a carpet of flowers hanging in front of them. They may fear that this is the onset of a serious mental illness and that they are hallucinating. Most often though, these illusions are the result of floaters, the brain misinterpreting distorted visual or audio information, or trying to supply information when there is no longer any stimulus. They are absolutely not a sign of mental illness.

Story 2

Mark Pampel sees patterns superimposed on everything like a film. He also sees flying saucers, which he says can be very disconcerting: 'It makes me stop in my tracks. People ask, “Are you all right, Mark?” and I say “Yes, I've just seen a flying saucer!” The first time I saw it I was shocked, absolutely shocked.' Mark's visual disturbances are caused by the Charles Bonnet effect.

A very few people do develop psychotic symptoms, of which hallucinations are a symptom, so it is important to establish whether someone is experiencing visual or audio illusions, or whether they are in fact hallucinating and so need treatment for a psychotic illness.

Mark Pampel has almost no sight, and uses two strong hearing aids. He no longer works, so he can pursue his passion for playing the piano. It's more than a passion, in fact: 'It's one of the things I do to keep myself from going completely barmy.'

Mark works hard to stay on top, he does yoga, uses an exercise bike, eats healthily, and goes to a Buddhist group to chant and meditate, appreciating their positive outlook. He says 'You've got to be aware of what your mind and body can tolerate. I stick to what I can do.' But even so, sometimes too much happens at once, and he hits crisis point.

This last occurred in 2001 when his eyesight deteriorated, he changed hearing aids, and his mother-in-law died of a brain tumour. Mark began to have problems sleeping so he went to see his GP. Over a succession of visits he was prescribed various sleeping pills and antidepressants, all of which seemed to make matters worse, not better. He was drowsy, but unable to sleep, and after the last set of pills, became exhausted and desperate: 'After three nights I knew I was going. I wanted to smash my head against the wall. I didn't know what to do. I tried to kill myself; I got loads of kitchen knives and cut at my arms. It hurt and didn't work so I dialled 999 to get help in cutting myself.'

Mark was taken to hospital, where a psychiatrist properly assessed Mark, and prescribed the right anti-depressants at last; he was referred to the psychiatric day hospital, and he began to recover.

The staff at the day hospital had little idea about deafblindness so Mark had to educate them. Best of all he found that they had a whole cupboard of musical instruments, so he set up a music group. Marks' determination seems to have paid off, not only did he recover, but also the hospital started to listen to his demands for a more deafblind-friendly environment. It was a grim experience, but as Mark says himself, 'I've suffered a lot, and come a long way.'

Many people, little support

It's only very recently that we've had figures showing how many deafblind people experience mental health problems, and these figures relate mostly to older people so we still don't have the full picture. None the less, their message is clear; deafblind people experience far more mental ill-health than do the rest of the population, including those who have a single sensory impairment.

• Four in ten deafblind people are sufficiently mentally distressed that they need professional help. (Bodsworth and Clare, 2006)

• Among older deafblind people, 15 per cent meet the criteria for possible clinical depression. (Fletcher, 2007)

• Mild cognitive problems, sometimes called 'confusion', were seen in 2.8 times as many older deafblind people as in older people without sensory loss. (Crews and Campbell, 2004)

Despite this high incidence of mental illness, few deafblind people get the help they need when they become ill, especially if they are over 65. Given that most deafblind people are over 65, this is very worrying.

There are two main barriers to a deafblind person receiving the right care: communication problems, and lack of understanding of deafblindness among professionals.

As we've seen, deafblindness does affect people's mental wellbeing, and unless a counsellor, GP, psychiatrist or other professional understands this they will not be able to help them fully. Unfortunately, few professionals know anything about deafblindness, they won't have received any training, and they probably won't have met another deafblind person.

If you don't use speech, few professionals will know how to communicate with you either. If you sign, you may have real problems opening the doors to health care via the GP or accident and emergency department, unless you have an interpreter. But this too brings its own problems, says Marylin Kilsby at Sense: 'If a BSL user becomes ill, their signing may become confused, so it is vital to call in a sign language user who's used to dealing with mental health issues. Where can you reach such people? There's Sign in London, and the regional centres in Birmingham and Manchester, and that's about your lot in the UK.'

Deafened and hard of hearing people may be lucky if they still have some hearing, or lip-read, but if they use deafblind manual or block, they will meet blank incomprehension in many places.

Story 3

A Deafblind UK worker turned up for a regular visit to a deafblind woman's home, but got no reply. The neighbour came over and said that the woman had collapsed in the street and been taken to hospital in an ambulance. They rushed to the hospital and were just in time to prevent her from being sectioned, as a deafblind manual user, she was sticking out her left arm for people to tell her what was happening, only for them to stick a needle in it, which brought a predictably distressed response.

Story 4

Sarah Reed's mother was, like most of her family, and Sarah herself, born Deaf. But later in life she had a series of mini-strokes that affected her vision. Sarah is clear that her mother's sight problems caused her mental health to suffer, although almost to the very end of her life neither the strokes nor her mother's mental illness were diagnosed. Sarah describes what happened after her mum became ill:

'It was awful, and I find it painful to talk about ... My mum became very anxious and felt that she had to be with my father all the time. He would leave to get the paper, but she would panic. Her fine motor skills were affected by the strokes too, so she was unable to sign and wasn't able to articulate what she wanted or how she felt. Also her memory was affected and she forgot how to sign. She withdrew into herself.

'My father started to get ill. He found it difficult to cope with my mum, but I have to give him his due, he never gave up. He was a traditional sort of man, and the roles were reversed when she became ill. My mum just gave up; she abdicated her responsibilities and focussed on herself and her illness. This wasn't the way she had been, she was a very determined woman, always laughing and joking.

'When we went to see the doctor, we used a local interpreter, and it turned out that they had a very basic knowledge of BSL, level 1. I was shocked because the minimum is level 4. We needed a specialist; my mum's signing was nonsense. I was telling the interpreter to voice over what my mum was saying so that the doctor could tell my mum was confused, but he refused. The doctor wasn't able to give an accurate assessment because the interpreter was wrong.

'Over a period of four years she progressively went downhill. It wasn't until four and a half weeks before she died, when she had a massive stroke, that she had a CT scan showing lots of lesions in her brain, she'd had lots of strokes over the years.'

Making us better

We all know that the system's not perfect, so what do we need to do to make it better? Sarah Bodsworth and Isabel Clare's interviewees identified four things they needed to help them cope:

• counselling around the time of diagnosis
• rehabilitation in daily living skills and mobility
• contact with others with the same condition
• specialised ongoing support, both emotional and practical

At a more basic level, Astrid Fletcher points out that simply giving older people decent hearing aids and eye care would greatly improve the quality of many lives.

Do we need specialist services for deafblind people? Most people think not, deafblind people are not a homogenous group; for one thing, they have different communication needs and backgrounds, depending on when they became deafblind and why.

Dr Margaret du Feu confirms this: 'a specialist service for deafblind people is probably not needed, provided, firstly that deaf services are better developed and have full awareness and training to work with deafblind people and secondly, learning disability and older adult services are similarly aware. It is very hard setting up specialist deaf services and I think to try and start a specialist deafblind service again, especially as there are relatively small numbers, would not be the most successful approach. I also think that counselling for sight loss should be developed, in the same way that hearing therapy helps people with hearing loss, and that both these counsellors and hearing therapists should be fully aware of the needs of deafblind people.'

Hearing therapists are in fact being phased out in the UK, as audiologists take on their therapeutic role. I asked the British Association of Audiologists about the new audiology training and they replied that new audiologists would be deafblind aware, although they would not be able to train deafblind people in new communication techniques. The courses are only two years old, so maybe some concerted pressure by deafblind people could persuade the BAA that more is needed?

How to keep yourself mentally healthy

Though we've focused on what happens when someone can't cope any more, that's only one side of the story. Many people do cope, and more than that, they enjoy their lives. Even if they sometimes wobble, the people I have talked to all have ways of keeping themselves healthy and positive. They won't all suit you, but give them a try, you might be surprised.

• Exercise helps lots of people to stay well, healthy bodies and healthy minds often do go together. You don't need to run a marathon, try Pilates or yoga for something less demanding but no less beneficial.

• Your diet makes a difference too: keep eating those five fruit and vegetables a day, and maybe try some health foods as well.

• Have interests, keep passionate!

• Work hard at keeping friendships going. If the going gets tough, talk to someone you trust. Make contact with other people who are deafblind, you can give each other mutual support and understanding.

• It's worth learning new communication tactics before receiving speech or BSL becomes difficult, it may reduce your fear of the future and ensure that you won't be isolated.

Sarah Reed at Sense, who has Usher herself, says ' I've found meditation very helpful for relaxation, to look inside myself and find things I hadn't thought about. I wasn't keen at first, but then I gave it a go, and other people noticed the difference. If you don't value your spirit you can be very lost. You have to look after your mind and body like a vehicle; they can't keep going with no maintenance!’

Where to find help

• If you are feeling really bad, or if you think you may harm yourself, go straight to your local hospital's accident and emergency department. Or contact the Samaritans; they are there to support you at any time, day or night, in complete confidence. The Samaritans are on 08457 90 91 92, or you can SMS (text) them on 07725 90 90 90 or email them at Jo@samaritans.org

• It can be really helpful to talk to a trusted friend about the way you feel. Many deafblind people find that talking to other deafblind people makes a big difference, they understand what it is like to be deafblind, and may well have felt just the same way as you do. If you would like to meet other deafblind people, get in touch with Sense and we can tell you about groups run by deafblind people.

• If you need more help than this, your first port of call is your GP. Through them you can be referred to specialists in mental health. It's very important that you and your GP can communicate freely. If you need help to do this, your GP must supply and pay for the support you both need. This is a legal requirement under the Disability Discrimination Act. You can ask to take along an interpreter or communicator guide with whom you are comfortable and familiar, but your GP should pay for their time. You can of course take a friend or family member, but only if you are comfortable talking completely openly in front of them.

• GPs can now buy a BSL software package to help them communicate with signing patients. Find out more at www.signhealth.net

Once you and your GP have talked, they may refer you to a counsellor. You can talk to the counsellor in complete confidence about the way you feel. Or your GP may refer you to a clinical psychologist or psychiatrist who will assess you further and decide how best you can be helped.

You can ask your GP to refer you to a counsellor if they don't suggest it. You could also contact the British Association for Counselling and Psychotherapy (at www.bacp.co.uk and 0870 443 5252), or your local Mind association, they may be able to give you the names of local counsellors. Your counsellor isn't likely to know much about deafblindness, so it might be useful to take along a Sense factsheet or this article to help them.

Treatment for mental illnesses may include drugs, or talking therapies such as psychotherapy or cognitive behavioural therapy. The treatment will depend on the nature and severity of your illness.

A really good source of information about different illnesses and their treatment is the charity Mind. You may have a local branch which you can visit, or you can go to their website at www.mind.org.uk . They also have a telephone helpline on 0845 7660163. In its local branches, Mind offers counselling, befriending, advocacy and many other services.

Sometimes it's hard to reach the mental health services you need. Several people I spoke to mentioned how useful their audiologist or social worker had been. They are often well plugged into the health service system and know how to get things done. They should also understand your communication needs, and be able to explain them to other professionals if you find this hard.

You can also contact Sense and we will support you. We don't have any mental health specialists ourselves but we can help you to get the services you need by working alongside you. Our outreach workers are ideally placed to do this with you.

Stop press!

This January, RNID announced that it is to launch a specialist mental health service for deaf and deafblind people. They will be setting up purpose-built 8-bed units for people with acute mental health needs. It's early days yet, so we don't know where the units will be, but it's a definite step in the right direction. Watch this space!

Specialist Deaf services

Deaf people who use BSL do have access to specialist mental health services. So if you need help and are a BSL user, you may be able to tap into these. Bear in mind though that these services are for Deaf people, and don't pretend to any expertise in deafblindness.

The charity Sign is an excellent source of information about these specialist Deaf mental health services, or you can contact the National Deaf Services directly. In addition, the British Deaf Association has a counselling service with signing counsellors.

National Deaf Services

National Deaf Services, Adult Service, Old Church, 146a Bedford Hill, London SW12 9HW.
Voice; 020 8675 2100 | Textphone: 020 8675 2200 | Fax: 020 8675 2266 | Videophone: 020 8765 9790

National Deaf Mental Health Services, Denmark House, Queen Elizabeth, Psychiatric Hospital, Mindelsohn Way, off Vincent Drive, Edgbaston, Birmingham, B15 2Qz.
Voice: 0121 678 2181 | Textphone: 0121 678 2185 | Fax: 0121 678 2179

National Centre for Mental Health and Deafness: John Denmark Unit, Bolton, Salford and Trafford NHS Trust, Bury New Road, Prestwich, M25 3BL.
Voice 0161 772 3400 | Textphone: 0161 772 3407 | Fax: 0161 798 5853

Sign
Tel: 01494 687 600 | Textphone: 1494 687 626 | Web: www.signcharity.org.uk

British Deaf Association/Sign Community Counselling Service
Voice: 01925 652520 | Textphone: 01925 652529 | Videophone: 01925 630169 | Fax: 01925 652526 | Email: yvonnet@signcommunity.org.uk
BDA counsellors are experienced in working with Deaf people, but are not clinical counsellors like those at the National Deaf Services.

Everything I've said so far talks about the help you should get. But we all know that our health service is thinly stretched, so you may not get it at first try. It is worth persevering. Under the Disability Discrimination Act, you have a right to mental health care, just like anyone else. Don't settle for less.

Have a cup of TEA
Towards Equality and Access is a project to improve access to health services for deaf and deafblind people. The Department of Health has given every Primary Care Trust funds to improve access, but so far there's little sign of where it has been used. Why not contact your own PCT and ask it what it is doing to help you reach the services you need? You can find out more about TEA at Sign's website.

Some useful organisations

Deafblind UK
Helpline (voice or text): 0800 132 320 | Web: www.deafblind.org.uk
Deafblind UK provides a free confidential 24hour telephone helpline service.

Carers UK An organisation of carers offering support and information.
Helpline for carers: Tel: 0808 8087777 | Web: www.carersuk.org

Depression Alliance Information and support to people with depression and their families and friends.
Tel 0845 123 23 2o | Email: information@depressionalliance.org | Web: www.depressionalliance.org

MDF The bipolar organisation A self-help organisation.
Tel 08456 340 540 | Email: mdf@mdf.org.uk

Rethink (for people in serious mental distress) National advice service.
Tel: 0845 456 0455 | Email: info@rethink.org

Sane Confidential helpline offering practical information, crisis care and emotional support 12 noon to 2am.
Tel: 0845 767 8000 | Email: sanemail@sane.org.uk | Web: www.sane.org.uk

NHS Direct A telephone helpline where you can talk confidentially to a nurse or information officer. Tel 0845 4647; textphone 0845 6064647; website with an encyclopedia of health problems www.nhsdirect.nhs.uk

Local mental health trust.
It's worth trying your local mental health trust's website. It will tell you who your local mental health teams are, and how to contact them, and it may also have useful information about mental illness.

The Mental Health Foundation
Tel: 020 7803 1101 | Fax: 020 7803 1111 | Email: mhf@mhf.org.uk

British Society for Mental Health and Deafness
Web: www.bsmhd.org.uk

European Society for Mental Health and Deafness
Web: www.esmhd.org

Bibliography

Beeston, Derek, 'Sad ending', The Guardian, March 14, 2007.

Bodsworth, Sarah M and Clare, Isabel CH, `Deafblindness and mental health: the mental health needs of adults with dual sensory impairment', University of Cambridge and Deafblind UK, paper read at BSMHD Conference, 25 May 2006. Paper in preparation.

Bolduc, Daniel, Brissette, Lyne, Lefebre, Gilles, 'Deafblindness and mental health: better understand to better intervene', Institut Raymond Dewar, Canada.

Crews, JE and Campbell VA, 'Visual impairment and hearing loss among community-dwelling older Americans - implications for health and functioning', American Journal of Public Health, 94(5), 823-9, 2004. Cited in a summary of research into the consequences of age-related sight and hearing loss by Ole E Mortensen, Director, and Bettina U Moller, Information Officer, the Information Centre for Deafblindness in Denmark, March 2007.

du Feu, Margaret and Fergusson, Kenneth, 'Sensory impairment and mental health', Advances in Psychiatric Treatment, 9:95-103, The Royal College of Psychiatrists, 2003.

Fletcher, Astrid, 'MRC trial of assessment and management of older people', paper presented to Sense seminar on the prevalance of dual sensory impairment, 16 March 2007.

© Sarah Butler