Diagnosis and assessment

Depression is a multi-dimensional disorder with emotional, cognitive and physical effects on patients1, all of which need to be recognised and assessed. Cognitive dysfunction in depression is often overlooked, however, both by patients and physicians.2,3 This can be easily rectified by the physician asking simple questions and observing patient behaviour during the consultation.

Cognitive dysfunction in depression is often overlooked... both by patients and physicians. 

For example, subjective complaints of ‘cold’ cognitive dysfunction can be elicited by asking simple questions such as [Barry H. Personal communication]:

  • Do you have difficulties making decisions either at home or at work?
  • Do you have difficulties reading newspapers, lecture notes or data at work, or following TV programmes or conversations?
  • Do you find yourself misplacing items such as keys, or have difficulties remembering names or shopping items, or lose track of tasks at home or at work?
  • Do you struggle to start or, in particular, finish common tasks, either at home or at work, due to these problems?

It is important to avoid any fears of dementia by reassuring the patient that the aim of these questions is to explore the cognitive symptoms of depression. Interviews with people who know the patient very well, such as caregivers, may be of value in the assessment of a patient’s cognitive function.4

Cognitive dysfunction in depression is often overlooked
There are several reasons why cognitive dysfunction in depression may be overlooked Physicians often prioritise other symptoms of depression for defining cure, such as interest, mood and suicidal ideation,3 and they may not pick up patient descriptors of cognitive dysfunction, especially in young adults who they don’t expect to show cognitive dysfunction. In addition, patients with depression are most likely to report symptoms associated with sleep, appetite or mood, and may not be aware of, or able to report all of their symptoms.2,3

The problem is exacerbated by poor access to comprehensive neuropsychological assessments of cognition4 and the lack of effective treatments for cognitive dysfunction in depression.5

A more comprehensive approach to the diagnosis of depression might incorporate cognitive assessment at early stages of diagnosis, since cognitive symptoms appear to be feasible early markers and targets for intervention in depression.6,7

Cognitive dysfunction in depression can be assessed objectively and subjectively as part of on-going management
Once recognised, on-going assessment of cognitive dysfunction is critical as part of the management of patients with depression moving forward, and can be achieved using objective and/or subjective tools. However, there is scope to improve the range of tools available for screening for cognitive dysfunction in patients with depression in routine clinical practice.

Objective Tests
A range of objective neuropsychological tests are available that assess the different ‘hot’ and ‘cold’ cognitive functions affected in depression.8 Cognitive tests for assessing the different domains of ‘cold’ cognitive function are shown in Figure 1. Examples for ‘hot’ cognitive assessments include the Cambridge Neuropsychological Test Automated Battery (CANTAB) Affective Go / No-Go test and the CANTAB Cambridge Gambling Task.9,10 However, objective neuropsychological tests are not widely available and results need to be understood in the context of the effect on patients’ daily functioning.4,6


Figure 1

Tests for the different domains of ‘cold’ cognitive function6

Visual Learning & Memory

Additional Switching

Verbal Fluency

Cognitive Flexibility

Phycho-Motor Speed


Working Memory

Verbal Learning & Memory

Visual reproduction 1 & 2

Trail making test B

Letter & semantic fluency

Wisconsin card sorting test

Trail making test A

Digit span forwards

Digit span backwards

Logical memory 1 & 2

Ray complex figure test 30-min delayed recall

Modified card sorting test

Digit symbol-coding

Spatial span forwards

Spatial span backwards

Ravlt total & delayed recall

Welcher memory scale visual memory index

Can tab id / ed shitf

Symbol digit modalities test

Cvlt-II total recall

Sd free recall & ld free recall

Hvlt total recall & delayed recall

Buschke’s srt total recall

Subjective Tests
Self-rated cognitive questionnaires are more feasible for use in clinical settings than neuropsychological testing. The British Columbia Cognitive Complaints Inventory, the Cognitive and Physical Functioning Questionnaire and the Perceived Deficits Questionnaire have been validated for use in patients with depression.11-13 

Clinician-administered depression rating scales such as the Montgomery-Åsberg Depression Rating Scale and the Hamilton Depression Rating Scale (HAM-D) also contain items that assess cognitive function; however, they are not sufficient in assessing the depth, breadth and impact of cognitive symptoms.

Despite the range of objective and subjective measures to assess ‘hot’ and ‘cold’ cognitive dysfunction, there is no accepted best practice for assessing cognitive function in patients with depression in clinical practice.

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. DSM-5. Washington DC: American Psychiatric Publishing, 2013.
  2. Demyttenaere K, Ansseau M, Constant E, Albert A, Van Gassen G, van Heeringen K. Do general practitioners and psychiatrists agree about defining cure from depression? The DEsCRIBE™ survey. BMC Psychiatry 2011; 11: 169.
  3. Brody DS, Thompson TL, Larson DB, Ford DE, Katon WJ, Magruder KM. Recognizing and managing depression in primary care. Gen Hosp Psychiatry 1995; 17: 93-107.
  4. Harvey PD. Is it possible to assess cognitive impairment other than with neuropsychological tests? Psychiatry (Edgmont) 2009; 6: 23-25.
  5. McIntyre RS, Cha DS, Soczynska JK, Woldeyohannes HO, Gallaugher LA, Kudlow P, Alsuwaidan M, Baskaran A. Cognitive deficits and functional outcomes in major depressive disorder: determinants, substrates, and treatment interventions. Depress Anxiety 2013; 30: 515-527.
  6. Lee RSC, Hermens DF, Porter MA, Redoblado-Hodge MA. A meta-analysis of cognitive deficits in first-episode major depressive disorder. J Affect Disord 2012; 140: 113-124.
  7. Pettit JW, Lewinsohn PM, Joiner TE, Jr. Propagation of major depressive disorder: relationship between first episode symptoms and recurrence. Psychiatry Res 2006; 141: 271-278.
  8. Lam RW. Depression. 2nd edition. Oxford: Oxford University Press, 2012.
  9. Roiser JP, Sahakian BJ. Hot and cold cognition in depression. CNS Spectr 2013; 18: 139-149.
  10. Rock PL, Roiser JP, Riedel WJ, Blackwell AD. Cognitive impairment in depression: a systematic review and meta-analysis. Psychol Med 2013; Oct 29 [Epub ahead of print].
  11. Fava M, Iosifescu DV, Pedrelli P, Baer L. Reliability and validity of the Massachusetts General Hospital Cognitive and Physical Functioning Questionnaire. Psychother Psychosom 2009; 78: 91-97.
  12. Lam RW, Saragoussi D, Danchenko N, Rive B, Lamy FX, Brevig T, White MK, Yarlas AS, Bjorner JB. Psychometric development of Perceived Deficits Questionnaire – Depression (PDQ-D) in patients with major depressive disorder (MDD). Slide presentation at the ISPOR 16th Annual European Congress, Dublin, Ireland, 2-6 November, 2013.
  13. Iverson GL, Lam RW. Rapid screening for perceived cognitive impairment in major depressive disorder. Ann Clin Psychiatry 2013; 25: 135-140.
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