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John is a 40-year-old professional man who was mentally very well and then over a few weeks developed difficulty sleeping, with loss of appetite and low mood. He had occasional thoughts of hopelessness, but did not seriously contemplate ending his life. He stated that he did not drink alcohol or take drugs.
John had started having difficulty functioning at work. He was less enthusiastic than usual, had less energy than usual and found it difficult to concentrate. His wife persuaded him to go to the doctor, who told him that he may be depressed.
John was advised by the GP to undergo cognitive behavioural therapy. He did as advised and took three weeks off work.
Over that time John was not working, he took some exercise and followed a diet as advised, did not drink alcohol, took the antidepressant medication prescribed and attended a therapist.
After three weeks John felt slightly better and returned to work. He went back to the doctor after a further two weeks and reported feeling substantially better, but he still reported finding work very difficult. He was not meeting his targets. He could not get back into ‘the swing of things’ at work and he felt his performance was not as good as at previous meetings.
Despite his improved depressive symptoms, it is likely that John has lingering cognitive effects and some lingering depressive symptoms. John’s GP advised him to stick with the medication, not to lose hope, that things will improve with time and to come back in a couple of weeks.
After a period of eight or nine weeks, John reported that everything was back to normal, but John’s full functionary recovery is more difficult to achieve.
“In other words, getting back to exactly how he was beforehand,” said Prof Brendan Kelly, Professor of Psychiatry, Trinity College Dublin, and Consultant Psychiatrist at Tallaght Hospital, Dublin. “There may be an effect of an episode of depression on his self image and how vulnerable he feels, but also there may be lingering depressive symptoms, albeit at a low level, or lingering cognitive symptoms which are difficult to put a finger on. People don’t come in saying ‘I have cognitive symptoms’, they come in saying ‘I still don’t remember things very well’, or ‘I still have some problems concentrating’. John’s case is typical enough; the person acknowledges substantial recovery but has a niggling feeling that, really, they are not back to themselves.”
Up to 20 per cent of people who suffer from depression have lingering cognitive problems and these can be difficult for patients to articulate and difficult for psychiatrists to detect and resolve, according to Prof Brendan Kelly, Professor of Psychiatry, Trinity College Dublin, and Consultant Psychiatrist at Tallaght Hospital, Dublin.
“Eighty per cent of people with depression recover fully [but] 20 per cent have ongoing problems and these could be recurrences or lingering symptoms,” he said. The lifetime risk of suicide in severe depression is 15 per cent but it is much lower with mild or moderate depression, Prof Kelly added.
There are different kinds of recovery, he continued, where there is resolution of the core symptoms of depression, so that there is improvement in mood, appetite and energy and sleep, but cognitive problems can still linger in depression.
Most people with depression will have a problem with memory and concentration and processing speed, and about 95 per cent of people with acute depression have cognitive problems as well as mood issues, said Prof Kelly. One of the challenges then for psychiatrists is that even following recovery, the cognitive problems remain, so approximately 40 or 45 per cent of people with full or substantial symptom resolution will still have cognitive problems, he explained.
The lingering cognitive problems are the big obstacle to be tackled when trying to re-integrate people with their life and to make full recovery from depression a reality, said Prof Kelly. However, one of the difficulties for those treating depression is that there is still not a lot of precise knowledge about the biology of what occurs.
The neurotransmitter disturbances in depression are poorly characterised, he said. “We know there are disturbances in the function of serotonin and noradrenaline and probably other neurotransmitters, but the biological understanding of the brain is not sufficiently nuanced yet, to know precisely why it happens. It is probably related to something to do with serotonin and noradrenaline but it not as simple as too much of one, or too little of the other. There is a pattern of dysfunction in several neurotransmitters that is likely to contribute to it; it is impossible to be any more biological than that.”
It was generally thought that when people with depression were having difficulties with concentration and thought processing, it was due to low mood and that someone whose mood is depressed will have less alacrity in their cognitive function, said Prof Kelly. However, evidence is emerging that because a patient’s cognitive function improves somewhat with mood, but not fully, then cognitive function seems to be partly independent of mood.
Cognition and mood recover at different rates in people coming out of a depressive episode, said Prof Kelly, but when people are on the way into a depression, the two decline in parallel. “It appears that all of these different domains of symptoms tend to occur at the same time,” he commented.
“It is very difficult to study people just before they become depressed in terms of their cognition, but all of the indicators are that the symptoms develop simultaneously over a period of time; it is the resolution of them that has been more staggered.”
Patients who have been suffering from depression may often say that while they are feeling better, they are having a lot of difficulty getting going again, getting back into things the way they used to, and back into the flow of their lives as was previously the case, noted Prof Kelly. “This does improve with time, but it can be slow to improve.
“It can be difficult to explain these lingering difficulties to patients, because often family members will say ‘you are visibly better, it is time to move on with things’, but the person may just, with good reason, feel unable to move on with things precisely as they were beforehand [as highlighted in the case report in this article]. It is difficult for patients and it can be a little dispiriting, and that recovery phase can be very difficult for people.”
The advice tends to be to continue with the treatment, said Prof Kelly, and these residual cognitive processing problems will improve with time, and they do improve with time.
There is evidence that up to perhaps 40 per cent of people, even one year after symptomatic recovery, can still have detectable cognitive problems, he pointed out. The people can function, but they have a niggling feeling that they are not back to functioning as they used to function before the illness. They are by no means severely disabled by this but it is a significant concern for them to feel they are not back to themselves, said Prof Kelly.
A great deal is achieved if people can understand that they can have lingering symptoms and to try and keep people focused on the areas of recovery rather than becoming disheartened by the areas that present continuing problems, he said.
“Psychological therapies can help a great deal with that and there is a job to be done in explaining to families how slow a full recovery can be from the point of view of cognition,” said Prof Kelly. Once a patient has achieved a substantial degree of recovery with an antidepressant, the incremental benefits are marginal, he continued. “It is difficult; there is no clear pathway at this point.”
A lack of full functional recovery in patients whose mood has improved can be concerning, according to Prof Kelly. The concern is because the highest risk for suicide in any episode of mental illness is the recovery period, where very often there is an uneven resolution of symptoms.
Sometimes, for example, in depression, successful treatment results in improved energy before it significantly improves depressive thought content, he explained.
This is a difficult situation if you have someone who still has depressive thought content but has more energy than they used to have, he continued.
The recovery period is a time of substantial risk and probably the highest risk period for self-harm or suicide in most mental disorders. This is evidenced by the fact that the highest risk period for suicide is following discharge from a psychiatric hospital because people have some symptoms but not others, explained Prof Kelly. “This period is a real concern.”
With regard to the lingering cognitive problems, patients do tend to improve, but it can take many months, even a year before a person feels ‘fully back to action’, the way they used to be, said Prof Kelly. “The antidepressant medications and the cognitive behaviour therapy can help a great deal with all of these symptoms, but these lingering symptoms can be difficult to detect — they can be difficult for people to articulate, let alone to characterise them and to treat them in a focused way, effectively.”