Cognitive Impairment in

Depression
Do cognitive deficits improve when depressive symptoms
improve?
Posted Jun 08, 2016

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Emotional processing, motivational processing, and cognitive processing each

require interactions within and among specific brain networks.
Common psychiatric illnesses involve varying degrees of dysregulation in
these three domains. Although major depressive disorder may be considered
primarily an illness of emotional dysregulation, it also involves significant
cognitive changes. What do we mean by cognitive changes? Cognition is
defined in the Psychiatric Glossary of the American Psychiatric Association as
“… the mental process of comprehension, judgment, memory, and reasoning
as contrasted with emotional and volitional processes.” The Merriam-Webster
Dictionary defines cognition as “the activities of thinking, understanding,
learning, and remembering.” Depressive disorders are associated with problems
in multiple cognitive domains including attention (concentration), memory
(learning), and decision making (judgment).

The cognitive changes associated with depression likely contribute to the

disabilities experienced by persons with this disorder. As reported by the
World Health Organization, major depression is one of the world’s most
disabling illnesses.

Many individuals with major depressive disorder respond to treatment. A

variety of antidepressants and evidenced-based psychotherapies can be
effective in diminishing the non-cognitive symptoms of depression. However,
the scales used to measure improvement in depressive symptoms do not
contain objective assessments of cognitive deficits, and clinical examinations
use relatively crude tools to assess changes in cognition.

In a recent study published in Lancet Psychiatry, Carrie Shilyansky and

colleagues describe the influence of antidepressant treatment on the cognitive
deficits associated with major depression.

Over 1,000 adults between the ages 18 and 65 (mean age of 37.8 years) who
suffered from major depressive disorder were enrolled into this study. None
was taking antidepressant medication at the start of the study. In order to
measure various aspects of cognition, the investigators administered a variety
of neuropsychological tests to individuals before and after treatment with one
of three antidepressants. This same 40-minute test battery was administered
to a group of age- and education-matched healthy persons in order to control
for the possibility of improved performance related to a practice effect of
taking the test battery twice.

Over the eight weeks of the study, approximately 45% of individuals

experienced remission of clinical symptoms after treatment with an
antidepressant. (Remission was defined as improvement below a specified
cut-off score on a depression rating scale, reflecting a low level of residual
symptoms.) The investigators wanted to know whether performance on
cognitive tests also improved in this group of people who responded to
treatment.

Prior to treatment, these individuals demonstrated diminished abilities in

seven cognitive domains: attention, response inhibition, verbal memory,
executive function, cognitive flexibility, decision speed, and information
processing. Following treatment and remission of clinical symptoms, these
individuals still demonstrated impairment in five of these seven areas. The two
cognitive areas that showed improvement were executive function and
cognitive flexibility.

For the purposes of this discussion, the exact nature of each of these cognitive
areas is less important than the fact that five of the seven cognitive domains
remained compromised after the non-cognitive symptoms of depression
improved. This suggests that persons with a history of depression may still be
handicapped by the cognitive deficits of this illness after other depressive
symptoms improve. This pattern occurred independent of which of the three
antidepressants was utilized.

In this study, only executive function and cognitive flexibility responded to

antidepressant treatment. These findings strongly suggest that different
components of the cognitive dysfunction associated with depression may be
differentially responsive to antidepressant treatment.

Psychotherapies, such as cognitive behavioral therapy, can lead to improvement

in the clinical symptoms of depression. Do effective psychotherapies also lead
to improvement in some or all of the associated cognitive deficits associated
with depression? This remains unknown. It is certainly possible that various
psychotherapies and pharmacotherapies could differentially influence the
cognitive deficits of depression. This possibility makes it imperative to
understand the magnitude and time course of cognitive dysfunction in the
context of depression. Individuals who have resolution of mood symptoms but
not cognitive symptoms could be at high risk for relapse, particularly when
they are trying to function in complex work and social environments where
their cognitive defects could impact performance.

It is important to recognize that major depression is associated with cognitive

impairment, which may persist after other symptoms of the illness remit. As
more research is done to elucidate the nature of these deficits and develop
better ways to treat them, hopefully we will be able to say that depression is a
fully treatable illness sometime in the future. In the meantime, it is important to
recognize that some people with depression may not be equipped to function
in complex environments, even when their mood symptoms are under control.

This column was written by Eugene Rubin MD, PhD and Charles Zorumski
MD.