Neuropsychological correlates in psychotic depression:Focus on attention

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Neuropsychological correlates in psychotic
depressionFocus on attention

• A.M. Politis, Athens Medical School, Department
  of Psychiatry, Eginition Hospital

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• 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
• .

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• 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.

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• 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

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Global Neuropsychological Performance of Healthy
Comparison Subjects and Patients With
Nonpsychotic Depression, Psychotic Depression,
and Schizophreniaa Healthy comparison subjects
meanlt0.01 (SD0.52) patients with nonpsychotic
depression meanlt0.01 (SD0.47) patients with
psychotic depression mean0.59 (SD0.91)
patients with schizophrenia mean0.95
(SD0.86). Hill SK Am J Psychiatry. 2004
Jun161(6)996-1003
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Performance in Six Neuropsychological Domains of
Healthy Comparison Subjects and Patients With
Nonpsychotic Depression, Psychotic Depression,
and Schizophrenia Hill SK Am J Psychiatry. 2004
Jun161(6)996-1003
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• 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.
• .

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• Ruffs 2 and 7 selective attention test is a
  paper-and-pencil number cancellation, visual
  search test, assessing an individuals
  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,"

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Specific features of attention

• selective attention
• effortless (speed and accuracy) does not
  recruit cognitive capacity to any great extent.
• ? S E 2 F ? P 7 H ? X H 7 ? G 2 T A P Y
  2
• effortful (speed and accuracy) requires attention
  to a larger extent,
• 3 2 7 9 3 2 6 4 3 7 5 6 1 3 4 5 9 8 7 0
  2 1 5 2 6 5
• sustained attention
• (Total speed and total accuracy )

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• 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

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Psychological Tests in Psychotic or
Nonpsychotic Depressed Patients, Patients With
Schizophrenia, and Healthy Volunteers (MANOVA)
Politis A, Lykouras L. et al 2004
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• 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

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• . 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 )

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• 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)

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Hamilton Depression Rating Scale comparison
Psycotic vs non psychotic (F3,52, P0,07)
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.
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• 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

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• 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

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. 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
individuals ability to discriminate relevant and
important information from irrelevant and
unimportant information Schatzberg AF 1985
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• 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

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• 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)