Three Questions to Ask to Assess Cognition in Depression

July 11, 2017
Rakesh Jain

In this new, occasional feature on Psych Congress Network, members of the Psych Congress Steering Committee answer questions asked by audience members at Psych Congress meetings.

QUESTION: What are your 3 favorite questions to assess cognition in depression?

ANSWER: Cognitive problems are unusually common in major depression and are often missed by both patients and clinicians. Missing identifying these symptoms comes with a heavy price for the patient. I therefore very much appreciate your question about how do we practically go about assessing for cognitive difficulties in depression.

Let's first appreciate that in major depression cognition is harmed in multiple domains—including attention, concentration, processing memory, and executive function. It is best to ask questions that directly address these domains. I would therefore recommend the following three questions as an initial screen to assess for cognitive difficulties:

  1. Do you find yourself having difficulties with forgetfulness and memory?

  2. Do you find yourself losing track of conversations, and have trouble with focus when you are reading?

  3. Do you find yourself having trouble making even simple decisions?

All three of these questions are good screening questions, and if difficulties are noted in any of these three domains, a more detailed assessment for cognitive difficulties should be conducted.

— Psych Congress cochair Rakesh Jain, MD, MPHClinical Professor, Department of Psychiatry, Texas Tech Health Sciences Center School of Medicine, Midland

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To Author,

I was affronted by a patient whom saw an Interventional Psychiatry for Fitness for Duty. Patient was scared because he had received a slight blunt force trauma three weeks prior but was cleared by neurologist. Patient has history of depression/anxiety. Patient told me he was very truthful about fear, shame and unability to work. He was given a MOCA test by the psychiatrist. He was distressed that after two and one half hours he struggled with drawing a cube and had trouble with naming 5 objects. More importantly was the response given by psychiatrist who says you were diagnosed wrong and he was bipolar. I want some feedback to give patient to explain to him that perhaps the anxiety of the evaluation, two hour interview and perhaps mood disorder aggravated by anxiety and the iconic not caring attitude of evaluator might have played into it. Please share some information on when to give a cogntive test in an interview? It did seem after a two hour interview to throw in 20 minute cognitive test might have been too much.  

I hear your legitimate concerns. I dont use the MOCA but I am familiar the structure of the test. Some of evaluations take 90 - 120 minutes because I perform the following paper and pencil tests: ACES questionnaire, Resilience score, GAD Scale, PHQ9, Holmes Rahe Stress scale and expanded Mini_Cog which includes the Three word Recall test, Clock drawing, Copying Cube, writing a sentence and a few praxis tests from MMSE I get into discussion of overall health, nutrition, exercise, use of complementary and alternative treatment medication lists, appropriate and safe med options[Based on 5 principles of Choosing Wisely], review of Co-occurring disorders Obesity, HTN, DMT-II, Cardiac disorders, Stroke risks, AUD, SUD, H/o head injuries, CTE from school sports or accidents and past Psychiatric diagnoses and treatment regimens, current medication list, recent UDS results, VS, Pulse oximetry results. There are times when I also do the CIWA and other withdrawal scales, Romberg, Pupils, EOM, gait, grip strength and drift.
I would be concerned with total score between the three word and clock diagram is 2-3 /6 and or the patients couldn't get the test done in the prescribed time limit. There are many reasons/motivations why depressed individuals may perform poorly. The way the interview is conducted that promotes a collaborative process and freedom to ask why questions e.g. Asking 5 questions can result in the patient experiencing the process as an effort to carefully listen and clarify facts to better understand the circumstances affecting the patient. If I a feel there are factors that are interfering with the performance I may repeat the Cognitive tests again on another day after getting an UDS, ordering pill counts after getting the med lists from pharmacies and querying State-Wide Prescription drugs monitoring system. It is amazing how this approach elicits information that the patient never thought would be of significance and has perhaps even forgotten. I would serially record the results and based on the total picture where all these pieces are placed I would offer my opinion which may include further testing and referrals to appropriate Neurologist and Neuro-psychologist. Concurrent factors of interest are Bereavement, Anniversary of losses, Trauma, high ACEs score, significant legal, marital, family, work stress and interpersonal conflicts. There may be also a feeling that this person cannot take the stress anymore and want to be assessed as being disabled. Some individual research what an individual must present with to get an affirmative assessment of disability. I try to create a conversational back and forth process by using Arthur Kleinman’s format for psychiatric interviews- in Kaplan and Saddocks. I have carried a copy from p1280 of 1989 edition of the textbook of the format in my wallet since 1989. Sample questions: What do you call what is causing you the most problems?  Why is causing you the problem now? What did it start when it did? what makes it better, worse, what treatments have you tried, what has caused most side effects and most/least benefit etc. I have used these questions especially in a systematic manner for 40 years. in all kinds of settings ER, ICU, IMCU, Post -Surgical ICU and in regular ambulatory clinical settings, in a plane or railroad station. I have used it with Glasgow Coma scale depending on the results.
Please feel free to contact me. Velandy Manohar, MD. Medical Director, Aware Recovery Care, North Haven, CT 06473