Rethinking Depression

Depression may be
more difficult to
decipher than expected

Fully understanding its complex
combination may open up new solutions.


Cognitive symptoms in MDD

Cognitive symptoms of depression are a common problem despite the availability of many treatment options and should be considered as part of the successful management of patients due to their high impact on quality of life.1,2

Additionally, these symptoms may be present regardless of improvements in other depressive symptoms2-6 and are a risk factor for disease relapse.7

This website is dedicated to exploring this developing area of research and furthering our understanding of the impact of these symptoms on patients suffering from depression, as well as potential management approaches.

Image 1

Cognitive symptoms are prevalent

Studies have also shown cognitive symptoms are the second or third most commonly reported symptom experienced during an acute episode of depression, among the diagnostic criteria for depression.1,2

How common are cognitive deficits?

Video 1

A study of 487 adolescents during their first depressive episode found that ‘diminished ability to think or concentrate or indecisiveness’ was reported by 83.2% of patients and was the second most common symptom. This included 76.8% of patients experiencing difficulties with concentration and thinking, and 45.4% with indecisiveness.3

A 3-year prospective study of 267 initially depressed primary care patients showed that cognitive symptoms, lack of energy and sleeping problems were present 94%, 90% and 85% of the time during major depressive episodes (MDEs) and 44%, 35% and 39% of the time during remissions, respectively.1

Further studies have confirmed that the cognitive symptoms of depression can persist even when patients are responding to treatment or are in remission.

A report characterizing residual depressive symptoms in a large sample of representative outpatients from the STAR*D study demonstrated that cognitive symptoms* persists in patients with MDD who have responded, but not remitted, to SSRI antidepressant medication, with as many as 71% of patients experiencing residual decreased concentration/decision making.4

*Concentration difficulties, indecisiveness and forgetfulness


The impact of cognitive symptoms

A study investigating the link between cognitive dysfunction and functional outcome in patients with major depressive disorder (MDD) demonstrated that cognitive performance was strongly associated with functionality, even when controlling for residual depressive symptoms.1

Presenteeism in depression

Video 2

It is thought that the presence of cognitive symptoms can significantly influence functional recovery.1 This makes addressing cognitive symptoms an important target for research.

Current research is exploring the degree to which cognitive symptoms, such as concentration difficulties, indecisiveness and forgetfulness, can explain impaired life functioning for a patient suffering from depression even 6 months after hospitalisation.1 After accounting for the effect of residual depression, psychosis and disabling co-morbidities at follow-up, studies have shown that cognitive symptoms are strongly associated with life-function disabilities 6 months after discharge from the hospital.1

Not only do cognitive symptoms of depression significantly impair daily functioning, they also increase the likelihood of relapse.1,2


Persistence & residual symptoms

The most prevalent residual symptoms of MDD, including fatigue and insomnia, have been studied for their impact on patient relapse. Many studies have found lack of full remission to be a key factor in patient relapse.1,2,3

Consequences of persistent cognitive symptoms

Video 3

Studies have also shown that residual symptoms are common in patients treated for MDD. In the STAR-D trial step 1, 15% of the patients responded but did not remit. Out of these responders the most frequently reported symptoms, assessed with the QIDS-SR16, were:

  • midnocturnal insomnia (81,6%)
  • sad mood (70,8%)
  • decreased concentration/decision making (69,6%)
  • low energy (63,3%)

Cognitive symptoms

Video 4

In one 3-year prospective study in 267 adult patients, cognitive symptoms, lack of energy, and sleeping problems were present 94%, 90% and 85% of the time during major depressive episodes and 44%, 35% and 39%of the time between major depressive episodes, respectively.5 The study defined cognitive symptoms as diminished ability to think or concentrate and/or indecisiveness.5

Furthermore, a cross-sectional study of the prevalence of cognitive and physical symptoms among 117 MDD patients in remission also showed that cognitive symptoms (defined by the study as apathy, inattentiveness, forgetfulness, word-finding difficulty, and mental slowing) were reported by more than 30% of the responders on antidepressants. In addition, lack of energy was present in almost 49% of patients and sleeping problems were present in greater than 50% of patients.1

The cognitive symptoms of MDD, such as lack of concentration, forgetfulness, and indecisiveness, are often refractory.1,5,6

Residual symptoms and persistence of cognitive difficulties may be associated with the impairment of daily functioning that can remain despite improvements in depressive symptoms.7 It is therefore recommended that patients with residual symptoms should continue treatment until these symptoms become of a minor degree or completely subside.8


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Last updated March 2012

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