Transcript athens-2005-s11

Neuropsychological correlates in
psychotic depression:Focus on
attention
A.M. Politis, Athens Medical School,
Department of Psychiatry, Eginition
Hospital

Impaired attention has been reported in several
psychopathological groups such as :
schizophrenia,
attention deficit hyperactivity disorder (ADHD),

major depression

Ackerman et all 1986, Nuechterlein 1984, Veiel 1997, Zakzanis 1999
.



Evidence has recently suggested that psychotic depressed
patients are more impaired, on neuropsychological testing
measuring attention as compared to non-psychotic
depressed patients
on the measures of psychomotor speed, motor skills,
attention, and learning
had more unsatisfactory scores on the Continuous
Performance Test
a significantly higher impairment in attention
Jeste et al.1998, Nelson et al 1998, Schatzberg et al 2000.


One avenue to better understanding of the neurocognitive dysfunction
associated with psychotic depression involves comparison with
clinically related conditions:
schizophrenia, with which psychotic depression shares psychotic
features, and diffuse and severe neuropsychological dysfunction
nonpsychotic depression, with which it shares affective symptoms.
Prior studies of patients with nonpsychotic depression have reported
executive and attention difficulties that are relatively benign,(effortful
mental operations, namely, those tasks that require selective and sustained attention,
or that necessitate larger amounts of cognitive capacity
Hartlage 1993, Zakzanis 1999
P.P. Roy-Byrne 1986, M.E. Tancer, 1990
Global Neuropsychological Performance of Healthy Comparison Subjects and Patients
With Nonpsychotic Depression, Psychotic Depression, and Schizophreniaa Healthy
comparison subjects: mean=<–0.01 (SD=0.52); patients with nonpsychotic depression:
mean=<0.01 (SD=0.47); patients with psychotic depression: mean=–0.59 (SD=0.91);
patients with schizophrenia: mean=–0.95 (SD=0.86).
Hill SK Am J Psychiatry. 2004 Jun;161(6):996-1003
Performance in Six Neuropsychological Domains of Healthy Comparison Subjects and
Patients With Nonpsychotic Depression, Psychotic Depression, and Schizophrenia
Hill SK Am J Psychiatry. 2004 Jun;161(6):996-1003
The study was designed to search for differences on
attentional performance among:
 unmedicated inpatients with major depression with
psychotic features,
 unmedicated inpatients with major depression without
psychotic features,
 in a control group of unmedicated schizophrenic
inpatients,
 in a healthy control group
and to determine whether these attentional deficits correlate
with the depressive symptomatology using, a visual search,
attentional test not previously employed in psychotic
depressed inpatients.
Ruff’s 2 and 7 selective attention test is a paper-and-pencil
number cancellation, visual search test, assessing an
individual’s attentional capacity to self-pacing targets for a
5-minute period in :
different distracting conditions known to influence selection
speed
 in one, the two numbers are randomly dispersed among
other digits; while selecting targets from the same stimulus
category is described as "effortful mental operation."
 in the second condition, the distractors are made of
alphabetical letters. Selecting targets from different
stimulus categories has been described as "effortless
mental operation,"

Specific features of attention
selective attention
effortless (speed and accuracy) does not recruit
cognitive capacity to any great extent.
ΔΣ E 2 ΦΥP7 HΥX H 7ΔΓ 2 TAPY2
effortful (speed and accuracy) requires attention to a larger
extent,
32793264375613459870215265
sustained attention
(Total speed and total accuracy )


Furthermore, the two-number target is more easily codified
in short-term memory and thus it is easily codified by
patients with memory disturbances
Finally, visual research of the target is categorical, and
selection of the two-number target is performed by patients
with a low educational profile
Characteristic
s
N
1
6
Male
8
Female
8
Patients
with
psychotic
major
depressio
n
N
1
6
8
Patients
with non
psychotic
major
depressio
n
8
N
2
0
Patients with
schizophreni
a
N
2
0
1
2
1
2
8
8
Healthy
volunteers
.
F
P
Age
49±15
54±13
41±9
55±1
6.7
3
0.00
1
Education
10±4
11±3
11±3
12±3
1.4
3
0.24
Duration of
illness
(months)
67±83
149±133
3.5
9
0.07
Number of
previous
episodes
patient
1.5±1
2±1
0.2
8
0.59
cy
t.a
cc
ur a
ed
t. s
pe
y
r ac
c.a
c
cu
ed
c.s
pe
cy
ur a
cc
a .a
a .s
pe
ed
60
50
40
30
20
10
0
scizophrenia
psychotic depression
depression
healthy
Post hoc, comparison, LSD test
Patients with
psychotic
depression
vs. Patients
with nonpsychotic
depression
Patients with
psychotic
depression vs.
Patients with
schizophrenia
Patients with
non psychotic
depression vs.
Patients with
schizophrenia
Automatic
speed
p=0.004
p=0.524
p=0.041
p=0.000
p=0.000
Automatic
accuracy
p=0.050
p=0.127
p=0.342
p=0.001
p=0.000
Controlled
speed
p=0.007
p=0.431
p=0.036
p=0.000
p=0.000
Controlled
accuracy
p=0.156
p=0.470
p=0.269
p=0.088
p=0.001
Total speed
p=0.003
p=0.311
p=0.064
p=0.000
p=0.000
Total
accuracy
p=0.032
p=0.091
p=0.260
p=0.022
p=0.000
Healthy
volunteers
vs. Patients
with nonpsychotic
depression
Healthy
volunteers vs.
Patients with non
psychotic
depression
Patients with
depression
non-psychotic
Vs Patients
depression
with
psychotic
P=0.011
Patients with non-psychotic
depression
Vs Patients with schizophrenia
p=0.04
Patients with non-psychotic
depression
Vs Healthy volunteers
p=0.000001
Patients
with
depression
psychotic
Vs Patients with schizophrenia
0.52
Patients
depression
psychotic
Vs Healthy volunteers
0.000
Vs Healthy volunteers
0.000
with
Patients with schizophrenia
Psychological Tests in Psychotic or Nonpsychotic Depressed Patients,
Patients With Schizophrenia, and Healthy Volunteers (MANOVA)
Politis A, Lykouras L. et al 2004



the present study indicates poor performance of psychotic
depressed patients in speed on target selection in both
effortful and effortless types of processing –selective
attention-and poor performance on overall speed and
accuracy-sustained attention- in the acute phase of the
disease.
confirm other studies on attention impairment
may underlie the specific mechanism that produces
impairment on selective and sustained attention
.
Our study evaluated subjects' attentional functioning not
only during the acute psychotic episode, so it does provide
data to clarify whether the attentional deficit in psychotic
depression is:
a state-dependent characteristic (which resolves with
remission of the acute episode),
a trait-dependent characteristic (and, thus, a possible
marker for this subtype of depression which improves but
does not fully resolve with remission of the acute episode )


The newer antidepressants (SSRIs) has a minor effect on
cognitive functions because of a lack of anticholinergic
side effects (Peretti et al 2000).
The atypical neuroleptics improved cognition in
schizophrenia such as verbal fluency, working memory,
executive functions and attention (Meltzer
1999)(Keefe,1999)
a.s
pe
ed
a.a
cc
ura
cy
c .s
pe
ed
c .a
cc
ura
cy
t.
sp
ee
d
t.a
cc
ura
cy
60
50
40
30
20
10
0
scizophrenia a
psychotic depression a
depression
healthy
Multiple Analysis of Variance (MANOVA) COMPARISONS BEFORE AND AFTER TREATMENT
Patients with
psychotic
depression
vs. Patients
with nonpsychotic
depression
Patients with
psychotic
depression vs.
Patients with
schizophrenia
Patients with
non psychotic
depression vs.
Patients with
schizophrenia
Automatic
speed
p=0.007
p=0.31*
p=0.04
Automatic
accuracy
p=0.07
p=0.15*
Controlled
speed
p=0.007
p=0.43*
Controlled
accuracy
p=0.35
p=0.84*
p=0.41
Total speed
p=0.006
p=0.30*
p=0.04
Total
accuracy
p=0.098
p=0.39*
p=0.351
p=0.61
p=0.02
Neuropsychological Differences between
patients with psychotic major depression
and patients with nonpsychotic major depression
could not be attributed to differences in severity of depressive symptoms.
50
45
40
35
30
25
20
15
10
5
0
Hamilton Depression Rating Scale comparison Psycotic vs non psychotic
(F=3,52, P=0,07)
Psychotic depressed vs schizophrenic
 From a quantitative point of view psychotic depressed
patients share the same pattern of attentional deficits in
both acute and remission phase with patients with
schizophreniasbut
Psychotic depression vs non psychotic depression
 the present study indicates that patients with psychotic
depression have qualitative and quantitative more
impairment on both selective and sustained attention as
compared to nonpsychotic depressed patients in both acute
and remission phase


In our study, psychotic depressed patients did more poorly
than schizophrenic patients. As mentioned, distractibility
(inability to direct attention away from irrelevant
backround stimuli) was once thought to be the hallmark of
the schizophrenic attentional deficit. It seems that this type
of disturbances is not specific to schizophrenia.
Cornblatt suggested that distractibility is a correlate of
psychosis in general and "probably vulnerability to
distraction is not a trait with predictive potential but a state
marker that is displayed by acutely disturbed patients with
psychotic symptoms“
Cornblatt B 1989
. Schatzberg propose that psychosis in depression may be
caused by increased cortisol levels, which may be more
pronounced in psychotic depression than in nonpsychotic
depression, leading to the greater neuropsychological
deficits, including decreased attention.
Increased cortisol levels may lead to less accurate
encoding of meaningful stimuli and may impair selective
attention, thereby reducing an individual’s ability to
discriminate relevant and important information from
irrelevant and unimportant information
Schatzberg AF 1985
To summarize,




The present study demonstrates that attention deficits exist
in major depression, it is more prominent in psychotic
depression.
It seems that these deficits may not be due to the severity
of depression.
The two depressive groups appear to differ both
quantitatively and qualitatively
Distractibility does not discriminate between depressed
and schizophrenic patients but may discriminate psychotic
from nonpsychotic depressed patients and it seems to be a
trait marker

These data not only provide additional support for
psychotic depression as a distinct mood disorder but also
document the considerable neuropsychological morbidity
associated with the disorder.

Psychotic major depression (or depression with significant
cognitive impairment) may biologically separate from
major depression
(Kopell BS 1970, Lyons DM, 2000 Schatzberg 2000)

Furthermore, taking attention as a criterion, psychotic
depression although of mood congruent subtype, is more
close to schizophrenia than to non-psychotic depression.
(Politis A , Lykouras L 2004)