A preliminary profile of neuropsychological deficits associated with major depression

Spinocerebellar ataxia type 8 in Scotland: frequency, neurological, neuropsychological and neuropsychiatric findings

OBJECTIVES

The objectives of this study were to: (i) establish whether the spinocerebellar ataxia type 8 (SCA 8) expansion is associated with ataxia in Scotland; (ii) test the hypothesis that SCA 8 is associated with neuropsychological impairment; and (iii) review neuroradiological findings in SCA 8.

METHODS

The methods included: (i) measurement of SCA 8 expansion frequencies in ataxic patients and healthy controls; (ii) comprehensive neuropsychological assessment of patients with SCA 8 and matched controls, neuropsychiatric interview; and (iii) comparison of patient and matched control magnetic resonance imaging (MRI) scans.

RESULTS

(i) 10/694 (1.4%) unrelated individuals with ataxia had combined CTA/CTG repeat expansions >100 compared to 1/1190 (0.08%) healthy controls (P < 0.0005); (ii) neuropsychological assessment revealed a dysexecutive syndrome among SCA 8 patients, not readily explained by motor or mood disturbance; neuropsychiatric symptoms occurred commonly; (iii) cerebellar atrophy was the only salient MRI abnormality in the patient group.

CONCLUSIONS

The SCA 8 expansion is associated with ataxia in Scotland. The disorder is associated with a dysexecutive syndrome.

Cognitive functioning in depersonalization disorder

Depersonalization disorder (DPD) is a dissociative disorder characterized by a subjective sense of unreality and detachment, and has been associated with deficits in perception and short-term memory. In this study, 21 DPD and 17 healthy comparison participants free of psychiatric disorders were administered a comprehensive neuropsychologic battery. The groups did not differ in full-scale, verbal, and performance IQ (Wechsler Adult Intelligence Scale), in working memory (Paced Auditory Serial Addition Test), or in selective attention (Digit Span with Distracters). The DPD group performed significantly worse on immediate visual and verbal recall (Wechsler Memory Scale, Revised), but not on delayed recall. Dissociation severity was significantly correlated with processing slowness and distractibility. We conclude that DPD is associated with cognitive disruptions in early perceptual and attentional processes.

[Executive functions in patients with depression. The role of prefrontal activation]

Depression is a multifarious disease, having an impact on most aspects of everyday life. Cognitive deficits cause considerable impairments and restraints in performance and have become one of the major clinical and research foci in recent years. According to previous work, deficits in executive functioning seem to be particularly prominent. At present only a few functional neuroimaging studies investigated the neurofunctional correlates aimed at these deficits by using specific activation tasks. These findings are somewhat controversial, revealing prefrontal hypo- as well as hyperactivation as a substrate of executive performance. This paper reviews current functional neuroimaging findings within a framework of depression as a dysfunction in limbic-cortical circuits. As a conclusion, the concept of "simple" hypofrontality does not offer a satisfactory explanation. Rather, a more dynamic model will be necessary in order to achieve a more realistic concept of executive deficits in depression.

Persistent cognitive impairment in depression: the role of psychopathology and altered hypothalamic-pituitary-adrenocortical (HPA) system regulation

BACKGROUND

Dysregulation of the hypothalamic-pituitary-adrenocortical (HPA) system and cognitive impairment are consistent findings in depression. This study examines the associations between HPA system regulation, cognitive functioning, and psychopathology in depressed inpatients on admission and at discharge.

METHODS

The HPA system dysregulation was evaluated with the dexamethasone (DEX)/corticotropin-releasing hormone (CRH) test. Cognitive assessment included speed of information processing, divided and selective attention, as well as short-term and working memory. Psychopathology was evaluated with the Hamilton Rating Scale for Depression (HAMD). Data from 75 depressed inpatients are reported, 51 (68%) of them achieved remission.

RESULTS

Despite a significant reduction of depressive symptoms between admission and discharge, a high rate of patients remained cognitively impaired. Selective attention improved significantly in remitters and nonremitters, while speed of information processing increased only in remitters. The cortisol response to the DEX/CRH test decreased significantly only in remitters, which was uncorrelated with cognitive performance. In nonremitters, severity of depression was significantly correlated with information processing time while improvement in short-term memory was negatively associated with the cortisol response at discharge.

CONCLUSIONS

Our data support the assumption that psychopathological symptoms and the HPA system dysregulation can be dissociated in their impact on cognitive functioning in depressed patients.

Successful computer-assisted cognitive remediation therapy in patients with unipolar depression: a proof of principle study

BACKGROUND

Despite increasing awareness of the extent and severity of cognitive deficits in major depressive disorder (MDD), trials of cognitive remediation have not been conducted. We conducted a 10-week course of cognitive remediation in patients with long-term MDD to probe whether deficits in four targeted cognitive domains, (i) memory, (ii) attention, (iii) executive functioning and (iv) psychomotor speed, could be improved by this intervention.

METHOD

We administered a computerized cognitive retraining package (PSSCogReHab) with demonstrated efficacy to 12 stable patients with recurrent MDD. Twelve matched patients with MDD and a group of healthy control participants were included for comparison; neither comparator group received the intervention that involved stimulation of cognitive functions through targeted, repetitive exercises in each domain.

RESULTS

Patients who received cognitive training improved on a range of neuropsychological tests targeting attention, verbal learning and memory, psychomotor speed and executive function. This improvement exceeded that observed over the same time period in a group of matched comparisons. There was no change in depressive symptom scores over the course of the trial, thus improvement in cognitive performance occurred independent of other illness variables.

CONCLUSIONS

These results provide preliminary evidence that improvement of cognitive functions through targeted, repetitive exercises is a viable method of cognitive remediation in patients with recurrent MDD.

Comorbid anxiety corresponds with neuropsychological dysfunction in unipolar depression

INTRODUCTION

Unipolar depressives seem apt to show neuropsychological impairment, particularly involving executive function and memory. Yet, not all depressed patients show such deficits. Major depressive illness shares a high rate of comorbid anxiety disorder, and anxiety disorders also tend to correspond with cognitive difficulties. Consequently, depressed individuals with comorbid anxiety disorders may be inclined to demonstrate greater neuropsychological dysfunction than those without anxiety disorders.

METHOD

We compared nonpsychotic depressed inpatients with (n=22) and without comorbid anxiety disorders (n=30) to a group of control subjects (n=38) on a brief but broad battery of neuropsychological tests. Patients were tested during an inpatient admission, and data were collected retrospectively from available records.

RESULTS

Both groups of depressed patients showed worse memory function than the controls. Yet, executive dysfunction and psychomotor slowing were specific to the depressed group with comorbid anxiety. The comorbid anxiety group also had more impaired scores than either the nonanxious depressed group or the control group. The depressed group without a comorbid anxiety disorder demonstrated no significant slowing compared to the control group.

CONCLUSIONS

Major depressive disorder corresponds with significant memory impairment, regardless of comorbid anxiety disorder. Yet, presence of a comorbid anxiety disorder coincides with deficits involving executive function and psychomotor slowing. Clinical and theoretical relevance of the data is discussed.

No association between the BDNF Val66Met polymorphism and mood status in a non-clinical community sample of 7389 older adults

Recent research has suggested that brain-derived neurotrophic factor (BDNF) may be implicated in the aetiology of mood-related phenotypes. Here we report an investigation of the association between a BDNF coding variant (Val66Met, rs6265) and mood status in a large non-clinical sample of men and women. We genotyped 7389 adult men and women, aged 41-80 years, selected from participants in the European Prospective Investigation into Cancer and Nutrition in Norfolk (EPIC-Norfolk, United Kingdom). Evidence of past year prevalent, lifetime and recurrent episodic major depressive disorder (MDD) and of past year prevalent and lifetime generalised anxiety disorder (GAD), defined by DSM-IV diagnostic criteria, was assessed through questionnaire together with a five-item version of the Mental Health Inventory (MHI-5). A total of 1214 (16.4%) participants reported lifetime MDD and 355 (4.8%) reported lifetime GAD. In this population based study we found no evidence to support an association between the BDNF gene Val66Met polymorphism and mood status.

Contribution of depression to cognitive impairment and dementia in older adults

BACKGROUND

The objective of this review is to provide information for clinicians regarding current research and opinions on the association of depression to conditions of cognitive impairment and dementia. We also intend to integrate this current research and thinking into strategies for the assessment and treatment of depression in the context of cognitive impairment.

REVIEW SUMMARY

Depression is highly prevalent in mild cognitive impairment and most dementias. It may be a risk factor for the subsequent development of dementia and in some conditions may be a prodromal symptom. It is important to detect and effectively treat depression because the comorbidity of depression and cognitive impairment is associated with greater cognitive and functional decline and higher rates of institutionalization. Depression often can be differentiated from Alzheimer disease and other dementias based on characteristics of clinical history and presentation. Screening of depression and cognitive impairment will help characterize the presence and severity of these conditions, but limitations in screening approaches may necessitate comprehensive assessment in complex cases where differential diagnosis is important to treatment planning.

CONCLUSION

Although depression and cognitive impairment are important issues in the treatment of older adults, there are particular risks when they occur together. Appropriate assessment and screening can help guide the clinician to appropriate and timely interventions. Pharmacologic and nonpharmacologic treatment approaches are both efficacious in reducing depression in cognitive impairment and dementia.

Obsessive-compulsive disorder: boundary issues

The boundaries between obsessive-compulsive disorder (OCD) and other neuropsychiatric disorders remain unresolved and may well differ from one disorder to another. Endophenotypes are heritable, quantitative traits hypothesized to more closely represent genetic risk for complex polygenic mental disorders than overt symptoms and behaviors. They may have a role in identifying how closely these disorders are associated with another and with other mental disorders with which they share major comorbidity. This review maps the nosological relationships of OCD to other neuropsychiatric disorders, using OCD as the prototype disorder and endophenotype markers, such as cognitive, imaging, and molecular data as well as results from demographic, comorbidity, family, and treatment studies. Despite high comorbidity rates, emerging evidence suggests substantial endophenotypic differences between OCD and anxiety disorders, depression, schizophrenia, and addictions, though comparative data is lacking and the picture is far from clear. On the other hand, strong relationships between OCD, Tourette syndrome, body dysmorphic disorder, hypochondriasis, grooming disorders, obsessive-compulsive personality disorder, and pediatric autoimmune neuropsychiatric disorders associated with streptococcus are likely. Studies designed to delineate the cause, consequences, and common factors are a challenging but essential goal for future research in this area.

The ecological validity of neuropsychological assessment and the role of depressive symptoms in moderate to severe traumatic brain injury

Evaluating the ecological validity of neuropsychological tests has become an increasingly important topic. Previous research suggests that neuropsychological tests have a moderate level of ecological validity when predicting everyday functioning. The presence of depressive symptoms, however, may impact the relationship between neuropsychological tests and real world performance. The current study empirically tests this hypothesis in a sample of 216 participants with moderate to severe traumatic brain injury (TBI) who completed neuropsychological testing, self-report of mood symptoms, and report of everyday functioning six months post-injury. Contrary to some previous research and clinical lore, results indicated that depression was weakly related to neuropsychological test performance, although it was more strongly related to everyday functioning. Neuropsychological test performance was also significantly related to everyday functioning. The ecological validity of the neuropsychological tests together was not impacted by depressive symptoms, when predicting significant other ratings of functional status. However, patient self-report seems somewhat less related to neuropsychological performance in those with significant depressive symptoms. Neuropsychological test performance was equally related to self and other report of everyday functioning in patients without significant depressive symptoms.

Influence of anxiety on electrophysiological correlates of response inhibition capacities in alcoholism

Anxiety disorders are highly prevalent in patients with alcohol use disorder. The purpose of the present study was to examine the neural correlates of behavioral inhibition in alcohol-dependent patients (ICD-10: F 10.2), and in healthy controls and to determine the influence of anxiety on these processes. Therefore, behavioral responses (reaction times; error rates) and event-related potentials of 16 patients with alcohol dependence syndrome and 16 age-and gender-matched healthy controls were recorded while the participants performed an auditory go/no-go task. The patient group was stratified according to their self-rated trait anxiety (STAI) with scores above and below median. We hypothesized that patients suffering from alcohol dependence would show reduced no-go P3 amplitudes involved in response inhibition compared to healthy subjects. In patients with alcoholism and high trait anxiety the decline of no-go P3 amplitudes was expected to be less distinct. The estimation of effect size based on the reaction times of patients with high and low anxiety ratings revealed a cohen's d of 0.61 indicating a small effect. High trait anxiety ratings were also associated with slightly enhanced no-go P3 amplitudes in central brain regions (Mean no-go P3 amplitude at Cz: 10.43 microV) compared to patients with low anxiety scores (Mean 8.98 microV). The effect size (cohen's d) revealed a small effect. Using the Mann-Whitney-U-test for independent samples of the comparison of high- and low-anxious patients, however, did not reveal any significant differences concerning no-go P3 amplitudes. Patients with alcohol use disorder and healthy controls did not differ significantly with regard to reaction time, error rate and no-go P3 amplitudes. This study suggests that no-go P3 amplitudes in patients with alcohol use disorder might be affected to some degree by habitual anxiety. The results emphasize the importance of monitoring trait anxiety in studies regarding cognitive functions in subjects with alcohol use disorder.

The relationship between psychological dimensions of depressive symptoms and cognitive functioning in the elderly - the MEMO-Study

Aim of this study was to examine the association of symptom dimensions of depressive symptoms and cognitive functioning in the elderly. In a population-based study with 365 participants 65-83 years of age, dimensions of depressive symptoms were assessed with the four subscales of the CES-D-score and standardized cognitive tests assessing attention, memory, cognitive speed, and motor speed were performed. Compared to men, women scored significantly higher on the subscales for depressed affect and somatic complaints. Older participants had a significantly higher score for interpersonal difficulties. Participants with lower education had higher scores on all four psychological dimensions of depressive symptoms than those with high education (only significant for depressive affect). Individuals scoring high on CES-D subscales for depressive affect and somatic complaints had statistically significant (after Bonferroni adjustment) lower scores in attention and motor function in multivariate analyses. No significant associations between the symptom dimensions of positive affect and interpersonal difficulties with any of the cognitive tests were found in univariate and multivariate analyses (after Bonferroni adjustment). Our findings suggest specific patterns in the relationships between symptom dimensions of depressive symptoms and cognitive dysfunction in the general elderly population. This novel approach might be useful in addressing the heterogeneity of cognitive impairment in depression and in predicting cognitive outcome in depression.

A study of the neural correlates of episodic memory and HPA axis status in drug-free depressed patients and healthy controls

Altered laterality of cortical activity, neuropsychological impairment and hypercortisolaemia have been shown in depression. The neural correlates of episodic memory in healthy subjects demonstrate hemispheric laterality but it is not known whether this is affected by depression and/or hypercortisolaemia. Twenty-seven drug-free depressed patients and 29 matched healthy controls were studied. Event-related potentials (ERPs) were recorded during an episodic memory test. During the study phase, subjects heard words spoken in either a male or female voice. Old and new words were presented visually during a test phase, when subjects were requested to identify words as old or new and recollect the gender of the voice for old words. Cortisol levels were measured in saliva and plasma samples. The results showed a trend for elevated salivary cortisol concentration in depressed patients. Reaction times were significantly longer in patients; however, there was no difference in memory accuracy performance between the two groups. Recollection performance was found to be negatively correlated with age, with a similar trend for cortisol concentrations. ERP activity not specifically related to episodic memory retrieval recorded 200-500ms post-stimulus from controls showed a marked laterality, with higher voltages over the right hemisphere; however, was not seen in patients. There was significant correlation between cortisol and the laterality of the neural activity specifically related to episodic memory retrieval recorded 500-1400ms post-stimulus in both depressed and healthy groups. These unique findings demonstrate that while the laterality of the neural correlates of episodic memory is sensitive to cortisol, it is not altered by the non-specific laterality effects seen in depression.

The WAIS-III and Major Depression: Absence of VIQ/PIQ Differences

Poor Performance IQ (PIQ) relative to Verbal IQ (VIQ) is a standard finding in depressed patients administered the Wechsler Adult Intelligence Scale-Revised (WAIS-R). This study examined performance of depressed subjects on the instrument's latest revision, the WAIS-III, which provides a more detailed subdomain profile of intellectual functioning. WAIS-III IQ, index and subscale scores were compared between 121 unmedicated subjects in major depressive episode and 41 healthy volunteers, using demographically adjusted T-score conversions. Depressed subjects had significantly lower PIQ scores, but neither the absolute VIQ/PIQ difference nor prevalence of VIQ/PIQ discrepancies >1 SD differed between groups. Index score differences were exclusively in Processing Speed, and subtest differences only on timed tasks. WAIS-III scores did not differ between subjects with major depressive and bipolar disorders, nor between subjects with and without melancholia or history of suicidal behavior. Results suggest general intellectual performance in depression is best characterized by deficits in processing speed, rather than global nonverbal abilities, and that this deficit is consistent across depression subtypes.

Psychological Disturbance, Incomplete Effort, and Compensation-Seeking Status as Predictors of Neuropsychological Test Performance in Head Injury

Indices from the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) representing cognitive and emotional disturbance as well as incomplete effort on the Recognition Memory Test (RMT; Warrington, 1984) were examined as predictors of performance on the Halstead-Reitan Neuropsychological Test Battery (HRB; Reitan & Wolfson, 1993). In the current study, which included a large sample (N = 369) of patients referred for neuropsychological (NP) evaluation after presumptive head injury, MMPI-2 measures of psychological disturbance accounted for as much as 25% of the variance in HRB test scores, resulting in a moderate overall effect size (median Adj. R(2) = .16; R = .40). When demographic variables, head injury severity, and compensation-seeking status were entered in previous steps, incomplete effort as defined by chance performance on the RMT accounted for between 2% and 13% of the variance in HRB test scores, with modest overall effect size (median R(2) Delta = .07; R = .26) in multiple regression equations. Additionally, when MMPI-2 indices of psychological disturbance were included in the last step, they accounted for 2% to 11% of additional variance, retaining a modest overall effect (median R(2) Delta = .03; R = .17). Compensation-seeking status and injury severity as measured by duration of post-traumatic amnesia were, at best, modestly related to NP test performance. Findings confirm the reliable relationship between test performance and psychological disturbance as well as incomplete effort when assessing dysfunction following head injury. In contrast to previous studies, incomplete effort was unrelated to compensation-seeking status.

A Meta-Analytic Review of Verbal Fluency Deficits in Depression

A prominent view in the neuropsychological literature is that depression is particularly associated with deficits in executive control processes. A meta-analysis of 42 studies with 2306 participants was therefore conducted to investigate the sensitivity of tests of verbal fluency to the pressure of this disorder, as there is a great deal of evidence that theses measures are valid markers of executive dysfunction. When the methodology adopted by other meta-analytic reviews was employed, semantic fluency deficits were found to be substantially larger than the phonemic fluency deficits. However, when a more rigorous method of meta-analysis was adopted, this indicated that the measure are in fact broadly equivalent in their sensitivity to depression, as has been found for patients with focal frontal lobe lesions. However, in contrast to patients with focal frontal lobe injuries, neither deficit qualified as a differential deficit relative to psychomotor speed. Therefore, for patients with depression, deficits on tests of phonemic and semantic fluency may not reflect executive dysfunction, but a more generalized impairment. Evidence is presented that tests of phonemic and semantic fluency may aid in the differential diagnosis of patients with depression and those in the early stages of dementia of the Alzheimer's type.

Neuropsychological impairment in major depression: its nature, origin and clinical significance

Neuropsychological impairment is well established as a feature of major depressive disorder (MDD) but studies have shown a variable pattern of impairment. This paper seeks first to clarify this by examining methodological and clinical factors that give rise to variability in study findings. Second, it examines theories of the origin of these neuropsychological abnormalities. Third, it reviews evidence regarding the clinical significance of different patterns of deficit. A selective review was undertaken of the literature with a particular emphasis on methodological factors, the influence of clinical subtypes and prevalent theories of neuropsychological abnormality. Methodological issues and the heterogeneity of MDD account for considerable variability in results. Specific investigation of the subtypes of psychotic MDD, melancholic MDD and bipolar depression reduces this heterogeneity and results are more consistent in the elderly. Hypothalamic-pituitary-adrenal axis dysfunction is associated with neuropsychological dysfunction in MDD although evidence of direct causation is not definitive at present. Impairment of executive and psychomotor function is a consistent finding, particularly in the elderly, and may reflect frontostriatal-limbic dysfunction. There is growing evidence that this may have clinical significance. It is suggested that future research take very careful account of the exact phenotype of MDD. Classification based on neuropsychological profile may, in fact, be useful. Further research should examine further the clinical importance of patterns of neuropsychological impairment.

Hippocampal abnormalities and memory deficits: new evidence of a strong pathophysiological link in schizophrenia

The central goals of this manuscript are (1) to better characterize what appears to be the most parsimonious account of schizophrenic long-term memory impairment in the neuropsychological literature: a contextual binding deficit rooted in the medial temporal lobes; (2) to link this deficit to concrete abnormalities at the level of the hippocampus; and (3) to suggest that this deficit could lead to the functional impairment experienced by schizophrenia patients in their daily lives. As far as long-term memory is concerned in schizophrenia, there seems to be a general agreement to conclude that explicit mechanisms are disturbed compared to relatively spared implicit mechanisms. More precisely, both subsystems of explicit memory (i.e., episodic and semantic) appear to be dysfunctional in this patient population. Errors during the encoding processes could be responsible for this dysfunction even if retrieval per se is not totally spared. Recently, a number of studies have suggested that impairments in conscious recollection and contextual binding are closely linked to episodic memory deficit. Since the hippocampal formation is considered to be the central element in the neural support for contextual binding and episodic memory, we have conducted an extensive review of the literature concerning the hippocampal formation in schizophrenia. Emerging evidence from varying disciplines confirm the coherence of the different anomalies reported concurrently at the neuroanatomical, neurodevelopmental, biochemical, and genetic levels. It seems highly probable that the synaptic disorganization in the hippocampus concerns the regions crucial for encoding and contextual binding memory processes. The consequences of these deficits could result in schizophrenia patients experiencing major difficulties when facing usual events which have not been encoded with their proper context.

Interviewing cognitively impaired older adults: How useful is a Cognitive Interview?

This research examined whether an Enhanced Cognitive Interview (ECI) and a Modified Cognitive Interview (MCI) improved 75- to 96-year-old adults' recall for a video-taped event. Specifically, we examined the effectiveness of these interviews in relation to a Structured Interview (control), and compared the performance of older adults who scored high or low on the Mini-Mental State Examination (MMSE), which is a test to assess cognitive functioning. Participants with low MMSE scores recalled fewer correct details, and were less accurate than those with high scores. Nevertheless, both high and low MMSE groups reported substantially more correct information about Action, Person, Object, and Surrounding details with the MCI and ECI than with the SI. No corresponding increase in the amount of incorrect and confabulated information was found. Furthermore, recall accuracy for both groups was greater with the ECI and MCI than with the Structured Interview. Overall, findings suggest that older individuals, including those with reduced cognitive ability can benefit from the use of Cognitive Interview protocols.

Education did not interact with major depression on performance of memory tests in acute southern Brazilian in patients

The relationship of cognitive function to depression in older adults has become a topic of extensive clinical interest and research.

OBJECTIVE

To analyze association between cognitive/memory performance,Major Depression, and education in 206 inpatients from the Psychiatry and Internal Medicine Departments.

METHODS

Patients were evaluated by the Mini Mental State Examination, a battery of memory tests, and the Montgomery-Åsberg Depression Rating Scale. Depression patients comprised 45 severe and 42 mild/moderate, according to the Montgomery-Asberg scale. The effect of psychoactive drugs was recorded (30% drug-free). Education was measured in years. Cognitive/memory tests assessed five domains: general mental functioning, attention, sustained attention/working memory, learning memory (verbal), and remote memory. An index for memory impairment was created (positivity: 50% of tests below cutoff).

RESULTS

The chief effect on worse performance was Major Depression for the domains (age and education adjusted) of attention, learning, remote memory, and general functioning. For the domain "sustained attention and working memory", only severely depressed patients differed from the medical controls (p=.008). Education showed an independent effect on test performances. No interaction between depression and educational status was observed.We also observed an independent effect of psychoactive drugs on some cognitive/memory domains. Logistic Regression showed Major Depression as the main risk for cognitive impairment.

CONCLUSIONS

These data demonstrated association of Major Depression with impaired cognitive performance independent of educational attainment or psychiatric medications.

Depressivität und Depression bei der Parkinson-Erkrankung

Zusammenfassung: Ein erheblicher Anteil an Patienten mit einer idiopathischen Parkinson-Erkrankung (PD) entwickelt im Verlauf eine sekundäre Depression. Die Prävalenzraten schwanken erheblich, da die Diagnosestellung aufgrund von Symptomüberschneidungen zwischen neurologischer Grunderkrankung und Major Depression (MD) erschwert ist. Dies führt zu Problemen bei der therapeutischen Indikationsstellung sowie zu einer eingeschränkten Interpretierbarkeit neuropsychologischer und neurophysiologischer Studien. Ein weiterer Aspekt bezieht sich auf Gemeinsamkeiten und Unterschiede zwischen sekundärer und primärer Depression. Entgegen dem klinischen Eindruck einer PD-spezifischen Depression erbrachten psychometrische Verfahren zur Depressionsdiagnostik diesbezüglich bisher nur unbefriedigende Ergebnisse. Ziele dieses Überblicksartikels: 1. Charakterisierung depressiver Syndrome bei der PD, 2. Überblick über den Forschungsstand zur Neuropathologie und Neuropsychologie, 3. Gegenüberstellung klinisch- und/oder neuropsychologischer Gemeinsamkeiten/Unterschiede zwischen sekundärer und primärer MD und 4. Konsequenzen für Forschung und Differenzialdiagnostik.

Neurocognitive function following remission in major depressive disorder: potential objective marker of response?

OBJECTIVE

Neurocognitive deficits have been widely reported in patients with mood disorders. However, relatively little is known of the short-term trajectory of neurocognitive improvement once treatment has been initiated.

METHOD

A neurocognitive test battery was administered to unipolar depressed (major depressive disorder, MDD) patients (aged 18-65 years) who had been medication-free for at least 6 weeks, and to healthy controls. Patients were then treated according to clinical need, predominantly with standard pharmacotherapy, and all participants were followed up within 6 months.

RESULTS

Of the 25 MDD patients who returned at follow up, 11 were defined as remitted and 14 as not remitted. Significantly less baseline psychomotor dysfunction was observed in patients who remitted compared to those who did not (effect size, d =0.78, 95% confidence interval (CI) =0.07-1.44). Analysis of the change scores between assessments revealed a significantly greater improvement in verbal memory in patients who remitted compared to those who did not (d =0.73, 95%CI =0.03-1.39).

CONCLUSIONS

This preliminary report suggests that there may be distinct temporal trajectories of neurocognitive improvement following remission in MDD. Aspects of neurocognitive functioning should be examined further as a means of providing a useful objective marker of treatment response.

Cognitive performance and subjective complaints before and after remission of major depression

INTRODUCTION

Patients with major depression report on severe cognitive deficits but objective neuropsychological test results indicate rather mild problems. In the present study we aimed at investigating neuropsychological performance, subjective complaints, and observer ratings of cognitive abilities in everyday life.

METHODS

Fifteen patients with major depression were studied in the acute state of illness and after remission. Fifteen healthy control subjects were investigated, too. A comprehensive neuropsychological battery, questionnaires for self and observer rating of cognitive abilities, and clinical questionnaires were administered.

RESULTS

As expected problems reported in self and observer ratings exceeded neuropsychological deficits in tests. Neuropsychological test results tended to be improved at the second test session, with patients showing a more pronounced improvement in flexibility.

CONCLUSIONS

The data support the hypothesis that cognitive problems in everyday life indeed exceed results in standardised tests. However, it seems also likely from our data that results are additionally influenced by patients negative self perception.

The association between depressive mood and cognitive performance in an elderly general population - the MEMO Study

The aim of this study was to analyse the influence of the severity of depressive symptoms on different domains of cognitive function in the elderly. In a population-based cross-sectional study, 385 participants aged 65-83 years were interviewed with the Center for Epidemiologic Studies Depression Scale (CES-D) and performed a standardized neuropsychological test assessing attention, memory, cognitive speed and motor function. Multivariate linear regression analyses revealed a significant effect of depressive symptoms on a single test (Stroop test 1) and two summary scores (memory and motor function). After full adjustment for education and Mini Mental State Examination, the memory score was partly attenuated. Stratified analysis showed that an increase in CES-D scores led to a larger decline of cognitive test results in participants with mild to moderate depressive symptoms, compared to those with a high degree of depressive symptoms. Our results suggest that depressive mood in older adults is primarily associated with decreased processing speed and motor functioning, but not executive control functions. According to our results depressive mood is not necessarily associated with memory deficits in older adults. Changes in depressive symptoms in milder forms of depressive mood are associated with a larger decline in cognitive function than in severer forms of depressive mood.

Deficits in visual functions and neuropsychological inconsistency in Borderline Personality Disorder

For Borderline Personality Disorder (BPD) cognitive and perceptual impairments were reported in some but not all studies. The aim of the present study was to analyze the neuropsychological performance of BPD patients in different domains. Predominant impairments of visual functions and an increased intra-individual variation of test performances within neuropsychological domains were expected. We investigated 22 patients with BPD and a matched sample of 22 healthy control subjects. A comprehensive clinical and neuropsychological test battery was administered. Effect sizes indicate primarily deficits of visual functions such as visual memory (Wechsler Memory Scale-Revised, WMS-R: Visual pair associates and visual reproduction, Complex Figure Test: Recall) and visuo-spatial abilities (Leistungspruefsystem, LPS 9 and 10: Spatial imagination and embedded figures), but also of executive functions (Tower of Hanoi, Trail Making Test-B, semantic and figural fluency, LPS 4: Reasoning). In addition, the intra-individual ranges of neuropsychological test results in BPD patients were increased compared to those of healthy subjects. This finding might be due to a high degree of temporary stress that interferes with effective cognitive processing. Further research is needed to confirm the present results and to control for stress during the test procedure.

Neurocognitive deficits and disability in major depressive disorder

Disability in life functioning is an important and poorly understood consequence of major depressive disorder (MDD). Mood symptoms do not account for the magnitude of disability resulting from MDD. Impairments in several domains of neurocognitive (NC) functioning have been shown to interfere with functionality in other psychiatric populations. These deficits, also present in MDD, may play a significant role in disability experienced by many with this disorder. The aim of this study was to examine the degree to which NC deficits, independent of affective and psychotic symptoms, explain functional outcome 6 months following hospitalization for a major depressive episode. Participants with an MDD diagnosis (N=48) received NC testing and symptom ratings while in the hospital. These procedures were repeated, along with functionality ratings, 6 months later. Six-month NC performance was strongly associated with functionality ratings after covariation for residual depression. Selected NC domains tested at baseline were predictive of functionality at 6 months. These data indicate that NC deficits, at least for some MDD sufferers, play an important role in functional recovery. New treatments, whether pharmacologic or rehabilitative, may be required to help affected patients accommodate neurocognitively based performance deficits at work, at home and in the community.

Musculoskeletal pain complaints and performance on cognitive tasks over the adult life span

The present study aimed at comparing participants with and without self reported musculoskeletal pain in a normal population with regard to performance on a range of tests for episodic memory, semantic memory, and other cognitive functions and to see if expected differences interacted with age. The results showed that participants with pain performed worse on a range of tasks as compared to participants without pain, and that these differences occurred regardless of age. The most robust effects of pain were displayed on tests for vocabulary and construction ability as these were the only effects that remained significant after controlling for years of education and reported depression in separate analyses. When depression and education were controlled for in the same analysis, even these effects were eliminated, suggesting interplay between pain, depressive status, and educational level in the negative effects on cognitive functioning.

Mood and neuropsychological changes in women with midlife depression treated with escitalopram

OBJECTIVE

This study assessed mood and neuropsychological function in a population of middle-aged women with major depressive disorder treated with escitalopram.

METHODS

Psychometric data measuring severity of depression were collected from 19 women and neuropsychological data were collected from 17 women aged between 45 and 65 years with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of major depression in a study in the Behavioral Neuroendocrinology Program at the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. All women were treated with escitalopram in an open-label design. Mean age was 55.94 years and mean number of years of education was 16.36 years. Diagnosis of major depressive disorder was assessed with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and mood was evaluated with the 21-item Hamilton Depression Rating Scale (HAM-D) at baseline and at weekly follow-ups for 12 weeks. Cognition was assessed at baseline and 3 months after treatment using a neuropsychological test battery, which included an abbreviated measure of Full Scale Intelligence Quotient, measures of attention and processing speed, verbal and nonverbal memory, executive functioning, and verbal fluency. Self-report data were collected on current menopause status and current hormone therapy use in the postmenopausal women. Paired sample t tests were used to analyze the change in total HAM-D scores and neuropsychological variables.

RESULTS

Statistically significant improvements were found in total HAM-D score, Wechsler Memory Scale III Logical Memory 1st Recall, I, and II scores, Wechsler Memory Scale III Visual Reproduction I scores, and Trail Making Test Part B scores. There was a statistically significant decrease in Controlled Oral Word Association Test FAS scores.

CONCLUSIONS

Treatment of depression with escitalopram in a population of middle-aged women was shown to improve mood and cognitive efficiency in complex attention, short- and long-term recall of contextual information, short-term recall of visual information, and cognitive flexibility; however, it was shown to worsen phonemic fluency.

Randomized treatment trial in mild traumatic brain injury

OBJECTIVE

To determine whether multidisciplinary treatment of mild traumatic brain injury (MTBI) improves neurobehavioral outcome at 6 months postinjury.

METHODS

Subjects with MTBI were randomly assigned to treatment (n=97) or nontreatment (control, n=94) groups. Treated patients were assessed within 1 week of injury and thereafter managed by a multidisciplinary team according to clinical need for a further 6 months. Control subjects were not offered treatment. Six-month outcome measures included: severity of postconcussive symptoms (Rivermead Post-Concussion Disorder Questionnaire), psychosocial functioning (Rivermead Follow-up Questionnaire), psychological distress (General Health Questionnaire), and cognition (neurocognitive battery).

RESULTS

Treatment and control subjects were well-matched for demographic and MTBI severity data. In addition, the two groups did not differ on any outcome measure. However, in individuals with preinjury psychiatric difficulties (22.9% of the entire sample), subjects in the treatment group had significantly fewer depressive symptoms 6 months postinjury compared with untreated controls (P=.01).

CONCLUSIONS

These findings suggest that routine treatment of all MTBI patients offers little benefit; rather, targeting individuals with preinjury psychiatric problems may prove a more rational and cost-effective approach.

Trail making test errors and executive function in schizophrenia and depression

The Trail Making Test (TMT) frequently is used as a measure of executive cognitive function. However, traditional use of test completion time as the primary outcome score does not give the more detailed information on cognitive processes that analysis of test-taking errors may provide. The present study compared TMT performance of three groups: patients with schizophrenia, patients with major depression, and healthy control participants (n = 30 for each group). Three operationally defined error types were examined: (a) tracking, (b) perseverative, and (c) proximity. Although both patient groups were slower than the healthy control group, only the schizophrenia group made significantly more errors, particularly tracking errors, suggesting a greater degree of cognitive disorganization. Within-group analysis of a larger group of schizophrenia patients (n = 84) revealed that TMT time was most strongly associated with the Withdrawal-Retardation factor of the Brief Psychiatric Rating scale. In contrast, TMT errors were most strongly associated with the Conceptual Disorganization factor. Comparisons of TMT scores and other cognitive tests showed moderate to high associations with tests of working memory, psychomotor speed, and executive function. Stepwise regression analysis revealed an independent association between Digit Cancellation and Part B Time, indicating a unique contribution of visuomotor scanning to performance. In contrast, Part B errors were uniquely associated with the Verbal Series Attention Test and the Token Test, tests of mental tracking and executive-mediated working memory, respectively. These findings demonstrate the utility of TMT error analysis in revealing cognitive deficits not traditionally captured using completion time as the sole outcome variable.

Cortical inefficiency in patients with unipolar depression: an event-related FMRI study with the Stroop task

BACKGROUND

The present study is aimed to examine the neuronal correlates of Stroop interference in medication-free patients with major depressive disorder.

METHODS

Sixteen patients fulfilling Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for unipolar depression and 16 healthy control subjects matched for age, gender, and education were included. All subjects underwent an event-related functional magnetic resonance imaging (fMRI) design with an adapted version of the Stroop task including congruent and incongruent task conditions. The fMRI experiment was conducted on a 1.5 T magnetic resonance (MR) scanner, and item responses were given manually by the subjects.

RESULTS

With regard to behavioral performance, patients revealed no differences in both reaction time and accuracy relative to control subjects. With regard to brain activations, direct comparison of patients with control subjects in the interference condition revealed hyperactivity in rostral anterior cingulate gyrus (rACG) and left dorsolateral prefrontal cortex (DLPFC) in depressive patients, which correlated strongly with the Stroop interference.

CONCLUSIONS

The study provides new evidence for the functioning and dissociation of the anterior cingulate in depressed patients. The greater prefrontal activation may reflect a cortical inefficiency due to hyperactivity in rACG enhancing the cognitive interferences from the emotional state.

Neuropsychological test profiles in schizophrenia and non-psychotic depression

OBJECTIVE

The study examined to what degree schizophrenia is characterized by a neuropsychological (NP) test profile specific in shape and level compared with depression and normal functioning.

METHOD

Fifty-three patients with schizophrenia, 45 with non-psychotic depression, and 50 normals were assessed with a comprehensive NP test battery and clinical instruments. NP test scores were factor analyzed into seven composite scores.

RESULTS

Schizophrenia patients performed significantly below normals across all seven composite scores, whereas depression patients were impaired in two. Verbal memory was most impaired. Sixty-two percent of schizophrenia patients were moderately or severely impaired, the corresponding figure for depression was 28%. Impairment was moderately associated with IQ level and clinical symptom load in schizophrenia, but not in depression.

CONCLUSION

Schizophrenia is characterized by deficits across a wide range of NP functions. Thirty-eight percent of the patients are within normal limits. A mild and limited NP disturbance is apparent in depression.

Cognitive performance in depressed patients after chronic use of antidepressants

RATIONALE

Depressive disorders are conditions that often require continuous treatment, and it is therefore important to evaluate the consequences of prolonged administration. There are few studies assessing cognitive functions of depressed patients after long-term use of antidepressants.

OBJECTIVES

This study evaluated the cognitive performance of depressed patients treated with antidepressants for at least 6 months.

METHODS

Patients with major depression (DSM-IV) using imipramine for 2.4+/-0.6 years (mean+/-SE), clomipramine for 2.8+/-1.2 years, fluoxetine for 1.8+/-0.3 years and sertraline for 1.5+/-0.3 years were compared to matched controls (sex, age and educational level) without any psychiatric diagnosis. Memory evaluation consisted of episodic, implicit and working memory tests as well as metamemory assessment.

RESULTS

(a) Psychomotor performance of patients taking imipramine was worse than that of controls in inserting pins and a visual reaction time task; on the performance of tapping the difference from controls varied according to dose/weight for patients taking clomipramine and fluoxetine. (b) For memory tests, differences between patients taking sertraline and controls were observed in the number of digits and words recalled; the difference between patients and controls varied according to dose/weight on the number of familiar words correctly completed for patients taking clomipramine and on digit span backward for those taking sertraline. (c) Metamemory was worse in all patient groups irrespective of patients' clinical state.

CONCLUSIONS

The impairment in psychomotor and memory performances associated with these antidepressants seems to be of low intensity and of questionable clinical relevance.

Resting anterior cingulate activity and abnormal responses to errors in subjects with elevated depressive symptoms: a 128-channel EEG study

Depression has been associated with dysfunctional executive functions and abnormal activity within the anterior cingulate cortex (ACC), a region critically involved in action regulation. Prior research invites the possibility that executive deficits in depression may arise from abnormal responses to negative feedback or errors, but the underlying neural substrates remain unknown. We hypothesized that abnormal reactions to error would be associated with dysfunctional rostral ACC activity, a region previously implicated in error detection and evaluation of the emotional significance of events. To test this hypothesis, subjects with low and high Beck Depression Inventory (BDI) scores performed an Eriksen Flanker task. To assess whether tonic activity within the rostral ACC predicted post-error adjustments, 128-channel resting EEG data were collected before the task and analyzed with low-resolution electromagnetic tomography (LORETA) using a region-of-interest approach. High BDI subjects were uniquely characterized by significantly lower accuracy after incorrect than correct trials. Mirroring the behavioral findings, high BDI subjects had significantly reduced pretask gamma (36.5-44 Hz) current density within the affective (rostral; BA24, BA25, BA32) but not cognitive (dorsal; BA24', BA32') ACC subdivision. For low, but not high, BDI subjects pretask gamma within the affective ACC subdivision predicted post-error adjustments even after controlling for activity within the cognitive ACC subdivision. Abnormal responses to errors may thus arise due to lower activity within regions subserving affective and/or motivational responses to salient cues. Because rostral ACC regions have been implicated in treatment response in depression, our findings provide initial insight into putative mechanisms fostering treatment response.

Pattern of impaired working memory during major depression

BACKGROUND

The aim of this study was to assess working memory (WM) in patients with major depressive disorder (MDD), using a robust parametric WM task (the n-back task).

METHODS

Twenty patients with MDD and twenty healthy controls completed a visual version of the paradigm, comprising four levels of task difficulty (i.e. 0-, 1-, 2-, and 3-back). Performance accuracy and reaction time (RT) were measured at each difficulty level.

RESULTS

In comparison with controls, patients with MDD exhibited slower RTs (F((1,38)) = 25.16, p < 0.001), and reduced accuracy (F((1,38)) = 5.93, p < 0.001). There was no diagnosis-specific effect of task difficulty on performance accuracy. However, the faster response to memory (1-3-back) than to shadowing (0-back) tasks observed in controls was not as pronounced in patients.

CONCLUSIONS

These observations support a relatively specific impairment of WM/central executive function in MDD, which may potentially mediate the diverse pattern of cognitive dysfunction noted in MDD. The parametric n-back task is applicable to subjects with MDD and yields results interpretable across the dimensions of task difficulty and performance in controls and patients.

Frontal lobe function in bipolar disorder: A multichannel near-infrared spectroscopy study

Frontal lobe dysfunction has been implicated as one of the pathophysiological bases of bipolar disorder. Detailed time courses of brain activation in the bipolar disorder group were investigated using multichannel near-infrared spectroscopy (NIRS), a recently developed functional neuroimaging technology with a high time resolution, and were compared with those in the major depression and healthy control groups. Seventeen patients with bipolar disorder, 11 equally depressed patients with major depression, and 17 healthy controls participated in the study. Changes in oxy hemoglobin concentration ([oxy-Hb]) during cognitive and motor tasks were monitored using frontal and temporal probes of two sets of 24-channel NIRS machines. [oxy-Hb] increases in the bipolar disorder group were smaller than those in the healthy control group during the early period of a verbal fluency task, larger than those in the major depression and healthy control groups during the late period of this task, and were smaller than those in the major depression group during a finger-tapping task. Depressive symptoms and antidepressant dosages did not correlate with [oxy-Hb] changes in the two patient groups. Bipolar disorder and major depression were characterized by preserved but delayed and reduced frontal lobe activations, respectively, in the present high-time-resolution study by multichannel NIRS.

WAIS-III and WMS-III performance in chronic Lyme disease

There is controversy regarding the nature and degree of intellectual and memory deficits in chronic Lyme disease. In this study, 81 participants with rigorously diagnosed chronic Lyme disease were administered the newest revisions of the Wechsler Adult Intelligence Scale (WAIS-III) and Wechsler Memory Scale (WMS-III), and compared to 39 nonpatients. On the WAIS-III, Lyme disease participants had poorer Full Scale and Performance IQ's. At the subtest level, differences were restricted to Information and the Processing Speed subtests. On the WMS-III, Lyme disease participants performed more poorly on Auditory Immediate, Immediate, Auditory Delayed, Auditory Recognition Delayed, and General Memory indices. Among WMS-III subtests, however, differences were restricted to Logical Memory (immediate and delayed) and Family Pictures (delayed only), a Visual Memory subtest. Discriminant analyses suggest deficits in chronic Lyme are best characterized as a combination of memory difficulty and diminished processing speed. Deficits were modest, between one-third and two-thirds of a standard deviation, consistent with earlier studies. Depression severity had a weak relationship to processing speed, but little other association to test performance. Deficits in chronic Lyme disease are consistent with a subtle neuropathological process affecting multiple performance tasks, although further work is needed to definitively rule out nonspecific illness effects.

Attention and executive functions in remitted major depression patients

BACKGROUND

Although deficits in attention and executive functions in patients with Major Depressive Disorder (MDD) are well confirmed [Veiel, H.O.F., 1997. A preliminary profile of neuropsychological deficits associated with major depression. Journal of Clinical and Experimental Neuropsychology 19, 587-603.]. The database regarding the relationship between impairments and the duration of disease or the number of episodes is inconsistent. Furthermore, the role of long-term cognitive impairments in MDD during remitted state is not well understood [Elliott, R., 2002. The neuropsychological profile in primary depression. Taylor and Francis, London, pp. 273-293.]. There is consequently a lack of studies accounting for different courses of illness in the euthymic state and considering the influence of possible attentional deficits on executive performance.

METHODS

40 euthymic patients with MDD diagnosis according to DSM-IV (20 patients with 1-2 episodes and 20 severe depressives with at least three episodes) as well as 20 healthy controls matched for education and age were administered three tests for attention (attentional shift, Stroop task, sustained attention) and three for executive functions (BADS, word fluency, memory span). The methods selected were theory based with regard to an involvement of frontal-subcortical networks in MDD, attention, and executive functions, respectively.

RESULTS

Euthymic patients with MDD showed deficits in all tests related to attentional and executive functions compared to healthy controls. The patient groups did not differ with regard to attentional performance. Executive functions in severe depressives were more impaired than in mild depressives.

LIMITATIONS

Differing performances of the patient groups in the subtests of the executive test battery (BADS) can only be interpreted to a limited extent.

CONCLUSIONS

The results support the assumption that deficits in attention and executive functions in MDD show an increase in trait character and executive function during chronic course. Implications for differential diagnosis and cognitive psychotherapy are discussed.

Chronic treatment with modafinil may not be beneficial in patients with chronic fatigue syndrome

Fourteen patients (7 male, 7 female, 22-63 years), classified as having chronic fatigue syndrome (CFS), but without concurrent major depression, significant sleepiness or use of psychoactive medication, completed a double-blind, placebo-controlled, crossover study of the effects of the selective wakefulness-promoting agent, modafinil (200 and 400mg/day). The treatment periods were each 20 days, with washout periods of 2 weeks. The primary aim was to determine effects on cognition and the secondary aim was to determine effects on self-ratings of fatigue, quality of life and mood. Modafinil had mixed effects in two cognitive tasks. In a test of sustained attention, treatment with 200mg reduced the latency to correctly detect sequences, but 400mg increased the number of missed targets. In a test of spatial planning, the 200mg dose resulted in a slower initial thinking time for the easiest part of the task, whereas 400mg reduced the initial thinking time for the hardest part of the test. Lastly, in a test of mental flexibility and one of motor speed, patients performed worse whilst on modafinil (400mg), compared with the placebo period. No effects were observed on the performance of other psychometric tests or on self-ratings of fatigue, quality of life or mood, but this may have been due to insufficient statistical power. It is discussed whether the limited and mixed cognitive effects that we observed could have occurred by chance, or whether a subgroup of CFS patients with daytime sleepiness would have shown greater benefits.

Executive functioning in depressed patients with suicidal ideation

OBJECTIVE

Suicidal thinking has been associated with cognitive rigidity, however, not all depressed patients contemplate suicide. Therefore, we hypothesized that compared with depressed subjects without suicidal ideation, depressed individuals with suicidal ideation would display poorer performance on measures of executive functioning that involve mental flexibility.

METHOD

In-patients with a current major depressive episode who had no current suicidal ideation (n=28) were compared with those who had current suicidal ideation (n=5) on measures of executive functioning and two neurocognitive tests that predominantly assess non-frontal regions.

RESULTS

Compared with non-suicidal depressed patients, depressed suicidal patients performed significantly worse on several measures of executive functioning after controlling for age, IQ, severity of depression and prior suicide attempts. The two groups performed similarly on tests that predominantly assess non-frontal regions.

CONCLUSION

Depressed individuals contemplating suicide have cognitive rigidity, which does not appear to be a global brain dysfunction. Suicidal mental states may result from dysfunctional executive decision-making that is associated with the frontal lobe.

Frequency and characteristics of recurrent major depressed patients with unimpaired executive functions

Major depression is associated with impairment of cognitive functions, and especially higher-order cognitive processes referred to as executive functions (EF). Whether this is a general finding is unclear. Patients without EF impairment may have different treatment needs than patients with EF impairment, and will probably have a better everyday functioning. Thus, it is important to identify the prevalence and characteristics of depressed patients without EF impairment. Forty-three patients with recurrent major depressive disorder (19-51 years) and 50 healthy controls were included in the study. The subjects were assessed with neuropsychological tests selected to measure central areas of EF, and screened on clinical and demographic variables. Within the depressed group, a total of 56% were defined as EF unimpaired. These patients were characterised by higher intellectual abilities and fewer depression episodes than the subgroup of patients with EF impairment. The subgroups were similar in age at debut of illness, severity of depression, general psychopathology and global level of functioning. In conclusion, about half of patients with recurrent major depression have normal EF. Since cognitive impairment and depressive symptomatology seem to be distinct dimensions, a neuropsychological investigation could help to ensure optimal treatment in patients with recurrent major depression.

[Place and role of neuropsychological exam in elderly depression]

PURPOSE

Neuropsychology provides essential information to all participants (physicians, psychologists, occupational therapists) involved in the treatment of the elderly. When treating depressed elderly patients, a comprehensive neuropsychological examination is required for diagnosis, prognosis and to control the effectiveness of antidepressant treatment.

KEY MESSAGE AND RECENT FACTS

Depression in elderly people is frequent and difficult to diagnose. Some forms of depression usher in or are associated with a neurodegenerative disease. In the case of diagnosis, the neuropsychological examination should furnish useful information to guide the clinician. The qualitative analysis of results (strategies used and type of errors) and the weakening of cognitive processes efficiency provides supplementary information and increases the reliability of the diagnosis. It also gives information about the long term evolution of cognitive deficits. It should reveal the presence of characteristics which help to distinguish patients who are developing dementia (predictive power of certain tests). Finally, it enables the clinician to evaluate the outcome of antidepressant treatment, to adjust the prescription according to the performance and to adapt an holistic treatment.

PERSPECTIVE AND PROJECTS

A neuropsychological examination may provide new perspectives, such as the possibility of predicting the outcome of dementia which are accompanied by affective disorders, such as Alzheimer's disease, vascular dementia and frontotemporal dementia. Neuropsychology may thus improve the treatment of these patients by providing information to a better understanding of their deficits and their impact on daily living abilities.

Limbic over-activity in depression during preserved performance on the n-back task

The profile of cognitive dysfunction observed in patients with major depressive disorder (MDD) may be partially attributed to a deficit in the central executive component of working memory (WM). This could be the consequence of a functional deficit in regions of cortex that are associated with WM function in healthy adults. In order to investigate this assertion, ten patients with a diagnosis of MDD and ten matched healthy controls undertook a parametric WM task (i.e. the n-back task) during the acquisition of blood oxygen level dependent echo planar magnetic resonance images (BOLD EPI fMRI). There was no significant difference in the behavioral performance of depressed patients and controls. This was true for both accuracy and reaction time on the n-back task. Random effects analysis of the functional imaging data (using SPM99) revealed a significant difference in load-dependent activation in the medial orbitofrontal cortex/rostral anterior cingulate between patients and controls (cluster size (K(E))/volume = 128/1024 mm3, P(corrected) = 0.025). While both participant groups exhibited a significant decrease in activation in this region with increased task difficulty, the magnitude of this decrease was smaller in patients with MDD than in controls. Therefore, this study implies that the performance of WM tasks is associated with a dysfunctional activation of the medial orbitofrontal and rostral anterior cingulate cortex in MDD. The study thus offers a rationale for explaining depressive cognitive impairment by the abnormal fronto-limbic activation found in clinical depression.

Selected executive skills in adolescents with recent first episode major depression

BACKGROUND

To investigate whether recent first episode major depression in adolescence is characterised by selected executive difficulties in attentional flexibility, behavioural inhibition and decision-making.

METHODS

Selected executive functions were compared in adolescents with recent (past year) first episode major depression (n = 30) and community controls (n = 49). Three computerised tests within the CANTAB battery were completed by all subjects (the Intra-Dimensional, Extra-Dimensional Set-Shifting task, the Affective Go, No-Go task, and the Decision-Making task).

RESULTS

Compared with controls, recently depressed cases displayed a bias towards negative stimuli with fewer errors on sad words as well as being more accurate in their responses to sad targets on the Affective Go, No-Go task. Cases also made faster decisions in the context of betting more of their available points compared to controls, as indexed by the Decision-Making task. These results were not influenced by age, gender, IQ, recent mood, severity of depression, medication or comorbidity.

CONCLUSIONS

Adolescents with recent first episode major depression show greater attention towards sad stimuli and more impulsive behaviour when making decisions. They were able to switch attentional set to neutral stimuli. This study demonstrates that computerised tests for measuring executive functions can be successfully deployed in adolescents, and suggests that specific patterns of neuropsychological functions may be relatively compromised in first episode major depression. These, together with their underlying neural substrates, deserve further investigation within this age range.

Cognitive Complaints Are Associated With Depression, Fatigue, Female Sex, and Pain Catastrophizing in Patients With Chronic Pain

OBJECTIVE

To examine the relation between demographic, pain-related, psychosocial, affective, and treatment factors and complaints of cognitive dysfunction among patients with chronic pain.

DESIGN

Cross-sectional survey.

SETTING

A university hospital outpatient multidisciplinary chronic pain program.

PARTICIPANTS

Chronic pain patients (N=222; 135 women, 87 men) completed a battery of psychometric questionnaires as part of an initial evaluation on referral to the program.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Cognitive impairment was assessed with items from the Brief Symptom Inventory; measures of depressive symptoms, pain intensity, posttraumatic stress disorder (PTSD), and pain catastrophizing were obtained from the Beck Depression Inventory (negative affect, negative self, somatic/physical function), McGill Pain Questionnaire, Modified Posttraumatic Chronic Pain Test, and Coping Strategies Questionnaire, respectively; and measures of subjective sleep disturbance, fatigue, opiate use, compensation/litigation status, pain location, and relevant demographic data were obtained from an open-ended questionnaire.

RESULTS

Correlational analysis indicated that female sex, pain intensity, PTSD symptoms, depressive symptoms, catastrophizing, pain location (neck), and fatigue were all positively related to cognitive complaints. Simultaneous regression analysis showed that all factors combined accounted for 52% of the variance in self-report of cognitive difficulties and that 6 variables had a significant unique contribution to the report of cognitive complaints in the following order of importance: depression-negative affect (beta=.28, P <.05), fatigue (beta=.17, P <.05), depression-somatic/physical function (beta=.16, P <.05), depression-negative self (beta=.14, P =.05), pain catastrophizing (beta=.12, P =.08), and female sex (beta=.12, P <.05).

CONCLUSIONS

Complaints of cognitive impairment among chronic pain patients appear to be associated with multiple factors, with particular attention to depressive symptoms, fatigue, and catastrophizing. Our results also suggest that women with chronic pain are particularly vulnerable to cognitive dysfunction.

Early depressive symptoms after stroke: neuropsychological correlates and lesion characteristics

OBJECTIVE

To examine the relation between depressive symptoms and specific cognitive functions in patients with a recent stroke and to examine associations with lesion characteristics.

METHODS

We studied 126 of 183 consecutive patients within 3 weeks after a first-ever symptomatic stroke (mean interval, 8.3+/-4.3 days). Presence and severity of depressive symptoms was assessed with the Montgomery Asberg Depression Rating Scale. Neuropsychological functioning was examined by means of a detailed neuropsychological examination covering six cognitive domains. We included a healthy control group (N=75) to obtain normative data for the neuropsychological examination. Functional impairment was measured with the modified Barthel Index and the modified Rankin Scale. Symptomatic and preexistent lesion characteristics were determined on CT or MRI.

RESULTS

Of the included patients, 40% demonstrated mild and 12% moderate to severe depressive symptoms. Severity of depressive symptoms was related to lesion volume (p=0.008), functional impairment (all p<0.004), and degree of overall cognitive impairment (p=0.005). After adjustment for lesion size, a specific neuropsychological profile emerged in patients with moderate to severe depressive symptoms, affecting primarily memory, visual perception, and language (all p<0.05). No association was found between severity of depressive symptoms and lesion location, presence of preexistent lesions (white matter lesions and silent infarcts), and demographic factors (age, education, and gender).

CONCLUSIONS

Moderate or severe symptoms of depression in the early stage poststroke are associated with a specific pattern of cognitive impairment, lesion size, and functional status. We suggest that depressive symptoms early after stroke are, at least in part, a reactive phenomenon secondary to severe cognitive and functional deficits.

Neuropsychological functions in anxiety disorders in population-based samples: evidence of episodic memory dysfunction

Most of the available evidence on neuropsychological functioning in anxiety disorders is based on clinical samples, investigating persons affected by obsessive-compulsive disorder. Knowledge is sparse regarding cognitive functions in other types of anxiety disorders. The aim of this study was to examine whether persons diagnosed with an anxiety disorder show neuropsychological impairments relative to healthy controls in tasks tapping episodic memory, verbal fluency, psychomotor speed, and executive functioning. Population-based samples comprising individuals affected by panic disorder with and without agoraphobia or agoraphobia (n=33), social phobia (n=32), generalised anxiety disorder (n=7), obsessive-compulsive disorder (n=16), and specific phobia (n=24) were compared with healthy controls (n=175) in test performance. Overall, the total anxiety disorder group exhibited significant impairments in episodic memory and executive functioning. Separate analyses on the respective anxiety subgroup indicated that panic disorder with and without agoraphobia, and obsessive-compulsive disorder were related to impairments in both episodic memory and executive functioning. In addition, social phobia was associated with episodic memory dysfunction. Verbal fluency and psychomotor speed were not affected by anxiety. Specific phobia and generalised anxiety disorder did not affect neuropsychological functioning.

General psychopathology is more important for executive functioning than diagnosis

OBJECTIVE

Impaired executive functioning (EF) has often been reported in patients with major depression or schizophrenia. We hypothesize that the variance in EF is more affected by level of general psychopathology than by diagnosis.

METHOD

Forty-three patients with major depression and 47 with schizophrenia were included. EF was measured with Wisconsin Card Sorting Test, Stroop Colour Word Test, Paced Auditory Serial Addition Test, Digits Backwards and Controlled Oral Word Association Test. The level of general psychopathology was measured with Brief Psychiatric Rating Scale - Expanded and Positive and Negative Syndrome Scale, the General psychopathology subscale.

RESULTS

The level of general psychopathology predicted more of the variance in EF than diagnosis. In multivariate analyses, the effect of general psychopathology on EF was more robust for adjustment for diagnosis than vice versa.

CONCLUSION

Future research on cognitive functioning in psychiatric patients should include level of general psychopathology to avoid overemphasising effects of diagnoses.