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Chairman Guy Goodwin introduced not only the speakers but also the audience to Pigeonhole live – the audience being enthusiastically encouraged to make use of their smart phones throughout this interactive meeting both to ask and answer questions via this medium. Traditional question cards were provided for the technologically-challenged!
Cognition needs to be treated differently from the other symptoms associated with MDD, Professor Raymond Lam, University of British Columbia, Canada, told the audience. Cognitive dysfunction in patients with MDD often persists into remission, and it is recognised that cognitive impairment drives functional impairment and, in particular, poor work functioning. This in turn means that patients who return to work are often working sub-optimally and this has associated costs – both financial costs for society but also costs in terms of the patient’s wellbeing. Work is important to patients, not just because of the money they earn – but as a source of accomplishment, intellectual stimulation, regular activity and social interaction.
As cognitive deficits affect a patient’s ability to functionally recover, new treatment options are needed to target cognitive dysfunction and better improve functional outcomes in patients with depression.
Which test is best in the assessment of cognitive dysfunction in MDD? This was the question posed by Dr John Harrison, VU University Medical Center, Amsterdam, The Netherlands and Metis Cognition Ltd.
An ideal test should be reliable, sensitive, valid, suitable for use in the long term, available in parallel forms and suitable for cross-cultural use. Dr Harrison cautioned the audience to do three things: choose the test to answer the question you want answered, remember that exploration informs confirmation and, most importantly, never be a slave to dogma. As he explained, tests to assess cognitive functioning in Alzheimer’s disease are insufficient and prone to a number of problems, yet they failed for 20 years because researchers were slaves to dogma!
In an assessment of the FOCUS study, cognition was successfully evaluated using the Digit Symbol Substitution Test (DSST) – suggesting that this would be a good candidate test for the assessment of cognitive dysfunction in MDD.
Interestingly, a Pigeonhole survey conducted during the meeting suggested that 70% of attendees already investigated cognitive deficits in their patients with MDD on a regular basis. However, 30% of attendees did not assess cognition regularly in their patients with MDD. Maybe those that don’t currently assess cognition in depression will find the THINC® Cognition Tool of interest.
Despite the increasing recognition of the importance of the assessment of cognition in MDD, as Professor Roger McIntyre, University of Toronto, Canada reported, no accepted and validated screening tool for the objective and subjective assessment of cognitive dysfunction in MDD suitable for use in daily clinical practice is currently available. Indeed, as he stated, what is needed is a tool to measure the extent of a deficit, not just aid in its identification.
This is the underlying rationale for the development of the THINC® Cognition Tool - a tool specifically developed to detect and measure cognitive dysfunction in MDD. The THINC® Cognition Tool incorporates several brief, easy to administer objective tests including the DSST, Choice Reaction Time (CRT), the Trail Making Test B (TMT-B), the One-Back Test (1BT) and the Pathfinder test as well as a subjective, patient reported assessment PDQ test. During the symposium a video demonstrating the objective tests was screened – showing the tests to be attractively designed and appealing to perform.
Currently, the THINC® Cognition Tool is being validated for the screening of cognitive dysfunction in adults with depression at the University of Toronto, Canada. It (along with many other useful materials concerned with cognitive deficiency in MDD) will be available to download from the THINC® website soon (THINCcognition.com). The tool will be free of charge and should be also be available in local languages.
‘Cognitive dysfunction in depression: are we THINC®ing about it enough?’ was the title of a well-attended satellite symposium sponsored by Lundbeck which took place on Sunday afternoon.
Curiously, not responding at all to pharmacological therapy may sometimes be better for a patient than a partial response, since lack of response forces a change in treatment.
With a partial response, both we and the patient may settle for second-best: a compromise outcome that leaves quality of life and functioning impaired. Perhaps the patient does not complain so much. They may be greatly improved on the standard assessments we apply. Symptoms are not as intense. But if we talk to them with time and attention we can see they are still not satisfied.
They are not as engaged with life as they used to be, and lack motivation and interest. They cannot plan long-term or make decisions. It is like walking through water, or driving a car with the brakes on. Perhaps they have other difficulties, such as anxiety. Though not a core symptom, anxiety is prevalent in depression and can be disabling since it is a great barrier to action and cause of insomnia.
This is surviving, not living. We have treatments that permit the next step. Yet we are perhaps reluctant to change the treatment for fear that what has been gained may be lost. The key, in my opinion, is to augment therapy rather than switch it again.
At this stage, there are several options. Prof Fagiolini stated that thyroid hormones are often not very effective and have side effects, with the risk of atrial fibrillation and osteoporosis. Lithium is a possibility but again there are side effects such as thyroid dysfunction, tremor and nausea. Another option is to add an antipsychotic. A depressed patient may not like the idea because they don’t have psychosis. But this is just a question of nomenclature, not efficacy.
We know that newer antipsychotics, which work on many different receptors and not just dopamine, can also be good as adjunctive treatment to antidepressants. Mechanism of action can be explained to the patient. Each of these agents has different side effects, and choice needs to be tailored to the circumstances of the individual patient. Some will appreciate a sedating action as a side effect, but others not. It is about striking the right balance.
An interview with Andrea Fagiolini, Associate Professor of Psychiatry at the University of Siena School of Medicine, Italy