Q: Is there a role for CBT in adult-age depression in trying to “target” cognition?

What I would say from a clinical standpoint is that—in older adults, at least—some newer therapies that are cognitive-behavioral in origin are directed toward some of the executive dysfunction that we see in patients with cognitive symptoms in late-life depression. So, they are directed toward things like organization and planning and initiative—ie, some deficits that don’t really respond well to medication or to certain psychotherapies. Specific psychotherapies that are being studied now might address the executive dysfunction syndrome of depression. This is a syndrome that we usually see in older adult patients who develop depression for the first time, let’s say, after the age of 55 or 60.

In terms of whether or not CBT helps the cognitive symptoms of depression, I think it may. Traditionally, I think of CBT as helping the mood and anxiety symptoms of depression. These techniques can also help patients with their distorted thinking that is related to their mood disturbance and depression—they help people reality test. And CBT helps patients develop more control over the way they feel. Thus, CBT may help, although I do not traditionally think of CBT as being the active ingredient in improving their cognitive impairment.

Sometimes, however, these “cognitive symptoms” (eg, attentional disturbance, distractibility, and forgetfulness) are anxiety-based symptoms. I think of the depressed mood in association with slowing down the thought processes and the cognitive processes; whereas anxiety may often contribute to the poor attention, distractibility, and forgetfulness.

I think that the notion of prevention is really interesting to develop further, and as Dr Forester alluded to, I am doing prevention research with colleagues in India. I have an interventional development grant from the National Institutes of Health. We are trying to develop scalable models of depression prevention for older adults at risk, particularly those in primary care. These models might have some utility since they use lay health counselors in low- and middle-income countries. This work is being carried out in Goa, India.

Interestingly, the model that we are using involves the principles of problem-solving therapy, a learning-based approach to psychotherapy that does seem to have some positive cognitive effects and depression prevention effects. Many people would consider problem-solving therapy a derivative of CBT as an activating intervention.

When one considers the success that has been seen with combined approaches that include CBT, such a multimodal approach seems to be a promising area for future development in the treatment of cognitive symptoms of MDD. If we were to take an antidepressant or a psychotropic agent that has demonstrated the ability to improve cognitive function, and we were to combine that with a behavioral intervention (eg, an aerobic exercise intervention, a sleep intervention, or a cognitive remediation intervention), might we achieve a multiplicative effect? Perhaps this would be much like CBT in combination with pharmacotherapy, which clearly produces superior outcomes in subpopulations with MDD.

To me, these are interesting questions: would there be synergistic effect of the pharmacotherapy with the behavioral intervention or cognitive remediation on the parameters that we measure, such as the digitalized cognition measures? And would those changes comport with some of the changes that we see in the brain?

For example, it may not be so much the white matter, but maybe there would be a more efficient reciprocity across and between circuitry in the brain—at least these circuits that are subserving cognition. These are areas of particular interest to me. And I think that performance and workplace attendance among those with depression, the presence of cognitive deficits and their severity, and perhaps also the type of cognitive symptoms, are all particularly germane here.