Q: How is cognition currently assessed, and what is the best measure of cognitive function in depression?

I think Dr McIntyre has spent a fair amount of effort thinking about this, and he should chime in more, but you can think of cognition measurements in the 2 extremes: there is the traditional neuropsychological approach that takes a long time, and that is clinically not viable; and then there are very short tests that may be more practical, but they do not give you all of the information that you would want. And Dr McIntyre, maybe you should talk about your recent efforts in this area.

Gladly, but let me back up just a step. I think all of us have contributed to the literature on measurement and measurement-based care broadly, and the clinical advantages that measurement-based care can provide, in terms of quantification and measurement, and as relates it to patient engagement. This applies to a variety of patient-reported outcomes and symptomatic outcomes.

However, it has always seemed peculiar to me that we never had a user-friendly point-of-care screening instrument for cognition – a point-of-care measurement or symptom-monitoring device to assess cognition. And I suspect, in large part, the field has not in the past given a lot of thought to cognition in depression. When we take stock of what is in use, there are quite a few tools that have been largely validated elsewhere.

The Mini–Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) are known for their screening role in dementia, but they are clearly insufficient in depression because of the so-called ceiling effect. That is, both tests have a limited ability to detect milder impairments. And the reality is, there’s just not the time, the access, the affordability to be sending each and every patient for a 3-hour neurocognitive evaluation. It’s just not going to happen; nor would we want that to happen.

There has been some interest, however, in a screening tool, a measurement tool for cognition, and that was created. I was one contributor, but there were about 18 contributors. It’s called the THINC-it^® tool. It’s a screening tool that is digital and self-administered (it doesn’t cost anything, and that helps), and it’s at the point-of-care – which I think is so critical. It has both objective and subjective ratings of cognition.

Always, just like other scales that we have, we try to find ways to make it even shorter (eg, we try to shorten the Patient Health Questionnaire 9-item [PHQ-9] to the PHQ-2) and we are going to shorten the THINC-it^® tool as well, but we wanted to have a starting point, at least.

I also think there is a broader issue here, however, and I think we all can agree that measurement of cognitive functioning has not taken place nearly as frequently as it should and could be taken. And it’s under that banner of measurements, and that sort of guiding principle of measurement, and one place I could see this sort of happening is in people who have persisting functional problems, even though they appear well. The dreamer in me would like to see cognition measured in just about every patient. I realize that is a quixotic fantasy, and so on, but I think that in certain patients – for example, that Silicon Valley CEO type that we talked about earlier – I see a role for it. Or, in other words, people who are receiving disability benefits, or who are being accommodated, people whose functional trajectory is simply not aligned with what the symptoms suggest they should be, and/or what their previous, premorbid functioning would suggest that they should be – this kind of thing should be assessed clinically. And they may not have frank dementia; we are not even speaking about frank dementia. We are speaking about deficits that could be clinically meaningful.

Dr Trivedi:
Sorry to interrupt, Dr McIntyre, but as somebody who, you know, developed the whole construct of measurement-based care from the Texas Medication Algorithm Project (TMAP) in the 1990s and then STAR*D, our first and most cited paper is on measurement-based care, and we even developed the terminology. And I have to say that you are being very modest about it.

It is unconscionable that we treat depression in this century without routinely using measurements. And then, when you speak of measurements, I think yes, we must think of symptom measurements like PHQ-9 or Generalized Anxiety Disorder 7-item (GAD-7). The impact of cognition is so huge that I would say that a short version like your THINC-it^®, or even shorter, measuring cognition in a wider population than just the CEOs, I think may be worthwhile. If you have a chronic lung disease or a chronic liver disease, your internist or primary care provider will take a fair amount of time to measure a lot of things before they continue treating you. I think we need to unapologetically recommend a similar approach for depression.

Dr McIntyre:
I couldn’t agree more. I have spent a great deal of my career working in health systems, fully aware of some of the barriers and perhaps also some of the enablers of measurement in practice. And I am beginning to believe that, unless there are the appropriate system engagements in this process, we are not going to see the utilization of measurement. We’d all like to see 100% measurement. I would mention though, that in the Journal of Clinical Psychiatry, we published the 2015 update for the Florida Best Practice Psychotherapeutic Medication Guidelines (FPG) for MDD. In those guidelines, there is a very strong, unapologetic statement that measuring depressive symptoms using a variety of scales – you mentioned them Dr Trivedi – and measuring function and measuring cognition should be the standard of care in every single patient – no exception. So, I think we need to have strong language like that to really get this out there. Ultimately, it’s going to take getting into the systems of healthcare and trying to convince people, dealing with reimbursement and so on, to make this all happen. So, that’s going to be a necessary part of it.

Clinicians have relatively few tools or options to address a cognitive problem, even if they define it (which is rare). For the most part, clinicians aren’t really looking, except in the most global terms, to make a determination about the degree of cognitive difficulty a depressed patient might have. So, it gets back to the point that this is an area (ie, cognitive deficits associated with depression) that has probably not gotten the focus that it deserves. But, let’s say that we recognize, because our patients are presenting with difficulties with attention, or working memory, or whatever cognitive domain it may be. What can we do about it?

I think that there is also the aspect of who pays for this – because it does take extra time. And in some cases there are extra resources that might reasonably be devoted to a majority of patients. I will tell you that, because of the work that Leanne Williams, PhD, has done here, because of our involvement in the International Study to Predict Optimized Treatment in Depression (iSPOT-D) trial, we are now in the process of, for every patient seen in the depression clinic in our resident clinic, among individual providers, we are using a tool that was developed by the Brain Resource Company. The tool is a 30-minute cognitive screen geared toward depressed patients, and we will have about 2000 patients who have been assessed using this screen. Now, it is a commercial screen, and I am not advocating the use of this particular screen, but it suggests that such screening may be possible. It is a 30-minute touch-screen, cognitive assessment that patients do not find burdensome. It can be done at the onset of treatment, and again we are using it as a research tool but we are also using it clinically, to inform our patients, residents, medical students, and so forth, about the importance of assessing cognition.

I suspect that there may be other tools out there that may be less expensive and less burdensome – 30 minutes may seem like a lot. Our average initial consultation is 1.5 hours and we now suggest that patients come 30 minutes ahead of time to complete some of this screening. And patients seem to appreciate that. They like the idea that we are taking the time to evaluate different aspects of their depression, and most patients recognize that their cognition is extraordinarily important, in terms of whatever they do.

Dr Trivedi:
I have to agree with you. We have developed an iPad-based application called VitalSign⁶, which is basically a measurement-based care tool for the screening, identification, and monitoring of depression in primary care. In the short span of 1 year, these clinics have screened 40,000 patients with this. So, I think going back to Dr McIntyre’s point, we will have to figure out a user-friendly approach to measurement-based care for providers. And Dr Debattista is also correct in that providers may have to be reimbursed for their efforts. But you know, this could be very similar to the model used in diabetes care.