Fully Treating Depression, Cognitive Symptoms and All

Care for Your Mind

Over the past several weeks, Care for Your Mind posts have articulated the “gold standard” of depression treatment: that it should be tailored for each individual living with depression, selected through a process of shared decision making that takes into account the person’s goals, priorities, and preferences. Based on those criteria, it’s reasonable for people living with depression and their families to expect to receive quality depression treatment from their primary care providers, particularly for the first and perhaps second medical treatment regimen. In this final post of the series, we underscore the importance of fully treating depression, meaning that treatment should not be considered completed until residual symptoms have been alleviated.

As discussed previously, major depressive disorder (referred to here as MDD or depression) can cause cognitive impairment, meaning it adversely affects a person’s thinking processes such as remembering, analyzing, making decisions, paying attention, and organizing, as well as processing speed. We have learned in research and practice that these cognitive impacts can outlast other depression symptoms and affect a person’s quality of life, interpersonal relationships, and performance at work or school. Nearly half of patients treated for MDD (~45%) experience residual symptoms related to cognitive impairment beyond when their mood-related symptoms have improved.

Frequently, people living with depression and their providers decide to terminate or significantly reduce the treatment regimen based on changes for the better in mood, sleeping and eating more regularly, experiencing fewer physical symptoms like headaches or digestive woes, and having less anger and irritability. However, when depression treatment is terminated prematurely – that is, before all symptoms are resolved – there are (at least) two negative results: people living with depression are less likely to regain their prior levels of functionality and are more likely to relapse into major depressive disorder.

As a matter of regular practice, in addition to making their own observations and engaging with the patient (and family members if applicable), healthcare providers should administer two types of validated tests at appointments with people being treated for MDD: one for emotional changes, and one to measure cognitive improvement in areas of working memory, executive function, and processing speed. Two validated and widely used self-report assessments for mood and emotional changes (or depression severity) are the Patient Health Questionnaire (PHQ-9) and the Beck Depression Inventory. Both are easy to administer and score.

For objective measurement of cognitive function, healthcare providers might use the THINC-integrated tool (THINC-it), the Trail Making Test B, and Digit Symbol Substitution Test. These tests target executive function skills that align with those commonly affected by depression. Comparison from one visit to the next should indicate the progress, if any, being made. It would be best to choose one measurement tool and stick with it, rather than alternating, so that you can better gauge changes in the cognitive functioning being assessed.

For people living with depression, improvement in mood should not necessarily mean the end of treatment. We want their feeling better to be long-lasting and we want the treatment to resolve all of the depression symptoms. Recovery of cognitive function is an issue for nearly half of adults treated for depression. Only by measuring progress and continuing treatment accordingly will people living with depression achieve the treatment outcomes they deserve.

Posts in the Depression Treatment series on Care for Your Mind

Our thanks again to the Takeda Lundbeck Alliance for supporting this series. Neither company nor their representatives were involved in content development or editorial review.

Resources and Readings

PHQ-9 (download)

McIntyre, R.S., et al., The THINC-Integrated Tool (THINC-it) Screening Assessment for Cognitive Dysfunction: Validation in Patients with Major Depressive Disorder

Jaeger, J., Digit Symbol Substitution Test: The Case for Sensitivity Over Specificity in Neuropsychological Testing

Cambridge Cognition, 6 Cognitive Tests for Research of Depression and Mood Disorders

Healthy Place, Cognitive Symptoms (Deficits) of Depression Test

Mattingly, G., et al., The Impact of Cognitive Challenges in Major Depression: The Role of the Primary Care Physician



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