It’s all about the patient

As many as 40% of people with MDD have been shown to have clinically meaningful cognitive impairments that affect their everyday function, work performance and quality of life. Yet this common feature of MDD is often overlooked when managing patients with acute episodes of depression and in patients who appear to be achieving an effective affective response to anti-depressant therapies.

These messages underpinned a clinical-case-based symposium at ENCP called “It’s all about the patient: clinical cases of cognitive dysfunction in major depressive disorder.”

Chaired by Professor Koen Demyttenaere of the Katholieke Universiteit Leuven, Belgium, the symposium considered two case vignettes which were discussed by a faculty comprising hospital-based psychiatrists as well as a primary care physician with interest and experience in the management of MDD.

It’s there… if you look for it

Professor Demyttenaere was keen to stress to delegates that cognitive dysfunction can be one of the defining features of MDD. He reminded his audience that current criteria for MDD actually embrace a number of symptoms and features that identify cognitive impairments as rooted within depression, often being hidden within the qualifying criteria for diagnosis – as Stuart Montgomery famously stated: “if you have all 13 of the 9 symptoms in DSM, you have MM”. By this he meant that many of the criteria for MDD actually encompass features indicative of cognitive deficit.

The symposium considered two clinical cases – the first a 25 year old female patient with MDD, on her second-line of antidepressant therapy who reported good improvement in mood but who had concerns about impairments in her ability to concentrate and function which were affecting her work performance and confidence. The second case was a 52 year old male presenting to his primary care practitioner with MDD, signs of an issue with alcohol and reports suggesting concomitant cognitive dysfunction.

Lively exchanges between the faculty – the chairman and psychiatrists Professor Bernhard Baune (Australia) and Professor Eduard Vieta (Spain) and Dr Sarah Bromley (UK) a GP and National Medical Director for Offender Health – ensured both cases were rigorously reviewed as well as discussed by delegates.

Delegates agreed that cognitive impairments can be both a driving or causal feature in MDD, and can emerge as part of the clinical picture of the condition both before and during treatment of mood-related symptoms.

Professor Baune stressed the need to dissentangle signs and symptoms of cognitive impairment associated with MDD from those that might be linked with comorbidities, concomitant therapies or ageing, for example.

The panel also discussed the need to consider symptoms of cognitive dysfunction in depression within the list of key symptoms that matter to the patient as issues to be tackled and resolved – particularly since these can have a dramatic impact on a patient occupational function and status.

Having meaningful cognitive dysfunction in MDD also has implications for the chosen course of patient management. The panel noted that while all MDD cases require an individualized approach to management, the presence of cognitive dysfunction should prompt consideration around choice of antidepressant and requirements for holistic management possibly incorporating counselling, psychotherapy and cognitive remedial and lifestyle management.

It’s also about stigma

Dr Bromley engaged with the panel and with delegates on the issue of whether patients with cognitive symptoms in depression and reporting occupational impairment, should be offered sick-leave as part of their management plan. On this topic Dr Bromley was ambivalent. She said that while stepping away from work might allow patients recovery time, it is essential to view options with care and from the patient’s perspective. She said that many patients could be fearful of being signed off work, fearing the stigma associated with a professional record showing absence due to depression.

Professor Baune said he hoped for a time when psychiatrists and primary care practitioners could work with employers to engender a culture accepting of work breaks and part-time working through serious mental health conditions such as depression.