0022-3018/85/1732-0120$02.00/0 THE JOURNAL OF NERVOUS AND MENTAL DISEASE Copyright © 1985 by The Williams & Wilkins Co. Vol. 173, No. 2 Printed in U.S.A. SINGLE CASE STUDY Focal Cognitive Deficits Accentuated by Depression BARRY S. FOGEL, M.D., anD F. R. SPARADEO, Pu.D.' A patient with a postoperative posterior right hemisphere lesion underwent neuropsy- chological testing during a major depressive episode, and again following remission of the depression. Qualitative visuoconstructive deficits typical of right hemisphere damage were present when the patient was depressed, but were absent following treatment of the depression. Verbal intelligence, cooperation, and vigilance were normal. The case suggests that depression may accentuate focal cognitive signs of fixed lesions in the absence of global impairment of function. Adverse effects of depression on cognitive function have been well documented in the psychiatric and psychological literature (14). Depressed patients have been shown to have reversible impairment of memory (5, 6, 21, 25), of abstract reasoning (2, 20), and of performance on cognitive and motor tasks requiring sustained effort (4). More specific impairment of right hemisphere function has been suggested in some neuropsychological studies of depressed patients be- fore electroconvulsive therapy (7, 11) and in a dichotic listening study in which depressed patients performed like patients with right temporal lesions (27). In pa- tients with known cerebral lesions, depression can interfere with neuropsychological test performance, particularly if it is so severe as to interfere with motivation or cooperation with the testing procedure (13). However, an effect of depression on specific cognitive functions in patients with known brain le- sions has not been documented. We report clinical and neuropsychological features of a patient with a posterior right hemisphere lesion whose focal cogni- tive deficits were apparently accentuated by depres- sion, despite good cooperation and attention, and in the absence of global cognitive impairment. Case Report A 28-year-old right-handed lawyer sought neuropsy- chiatric evaluation because of depressed mood, de- creased concentration, impaired memory, and diffi- culty organizing legal arguments. Nine months before the evaluation, he had undergone resection of a right parietooccipital arteriovenous malformation. (Repre- sentative postoperative computerized axial tomogra- phy scan cuts are shown in Figure 1.) Elementary * Department of Psychiatry and Human Behavior, Brown Uni- versity, Providence, Rhode Island. Send reprint requests to Dr. Fogel, Jane Brown 5, Rhode Island Hospital, Providence, Rhode Island 02902. neurological signs postoperatively were limited to a left homonymous hemianopia and unsustained left ankle clonus. Four months after surgery he developed simple partial seizures consisting of flashing lights; these were totally controlled with phenytoin and phenobarbital. Six months after surgery and shortly after returning to work, he developed a depressed mood, which evolved over the next 3 months into a major depressive episode with impaired appetite, weight loss, early morning awakening, and anxiety. On neuropsychiatric evaluation 9 months after sur- gery there were no new motor or sensory signs; the patient’s mental status was consistent with a major depression without gross cognitive impairment. Phenobarbital was discontinued because of concern over possible psychotoxicity but this did not lead to any improvement in mood or in subjective cognitive complaints. The patient remained seizure free on phenytoin alone, at a blood level of 20 ywg/dl. After phenobarbital had been withdrawn for 3 weeks, neuro- psychological testing was performed. The patient was reassessed independently by both authors within 1 week of the neuropsychological test- ing. At that time, he met DSM-III (1) criteria for major depressive disorder. Positive criteria included persistent dysphoric mood, recent weight loss, early morning awakening, psychomotor retardation, de- crease in sexual drive, loss of energy, frequent self- reproach, and subjectively impaired concentration. Suicidal thoughts were mentioned to the first author. A Hamilton depression rating (9) at that time, retro- spectively derived from the authors’ detailed contem- poraneous notes, was 21. Neuropsychological testing showed deficits in mem- ory, visuoconstructive, and visuoperceptual functions. Wechsler Adult Intelligence Scale (WAIS) (24) Verbal IQ was 125. Comprehensive language testing was nor- mal; the Wisconsin Card Sorting Test (8), Trail Mak- ing Form B (17), and finger sequencing were also FOCAL COGNITIVE DEFICITS AND DEPRESSION 121 Fic. 1. Postoperative computerized axial tomography scan, showing right temporoparietooccipital defect. performed normally. WAIS block design, a clock- drawing task, and visual reproduction subtest of the Wechsler Memory Scale (WMS [23]) all showed changes typical of right hemisphere dysfunction, in- cluding loss of configuration, perseveration, and ro- tation (12). (See Figures 2A, 3A, and 4A, and Table 1.) When evaluation was complete the patient was Fic. 3. A) immediate recall of design, first testing. (Model essen- tially the same as B.) B) immediate recall of design, second testing. Fic. 2. A) spontaneous clock drawing, first testing. B) sponta- neous clock drawing, second testing. 122 FOGEL AND SPARADEO BL Fic. 4, A) delayed recall of designs, first testing (models essentially the same as B). B) delayed recall of designs, second testing. treated with desipramine, 50 mg t.i.d., which produced a steady-state blood level of 166 ng/ml. He also re- ceived psychotherapy which focused on his adaptation to his deficit and his emotional reaction to the trauma of surgery. After 8 months the patient’s depression was in full remission and neuropsychological testing was re- peated. At this time independent assessments by both authors confirmed that DSM-III criteria for major depression were not met; the Hamilton depression rating, retrospectively derived, was 3. On this testing, the patient showed no memory deficit, and his Wechs- ler memory quotient had increased from 110 to 128. The major contributor to the improved memory score was a marked improvement in visual reproduction, with the raw score increasing from 8 to 13. The patient’s performance on visuoconstructive tasks showed significant qualitative improvement, with no broken configurations or reversals on a block design task, a normal clock drawing, and accurate reproduc- tion on copying from memory. (See Figures 2B, 3B, and 4B, and Table 1.) The patient’s Performance IQ on the WAIS was unchanged. However, his low scores were now entirely due to slowness. Qualitatively, his approach to all the subtests was normal. The above changes in test performance were accom- panied by subjective improvement in the patient’s capacity to work as a lawyer, and particularly in his ability to organize complex arguments. Comment © The data strongly suggest that this patient showed significant improvement in cognitive function be- tween the ninth and the 17th postoperative month. In addition to the impressive and consistent qualitative improvements in test performance, there was a sub- stantial change in the Wechsler memory quotient, attributable mainly to improvement on the visual reproduction subtest. While the test-retest. reliability literature for the WMS is not broken down by sub- tests, the overall test-retest reliability of the WMS may be as high as .80 (16, 22), which offers support to the idea that there was a real change in visual memory function. Literature on recovery of function suggests that the rate of recovery of higher cortical functions following brain injury drops significantly after the first 6 months (10). While some recovery of function can continue for years following a brain injury, the occurrence of a dramatic qualitative change between the ninth and the 17th month after surgery suggests that the pa- tient’s depression accentuated his deficit, and that antidepressant treatment alleviated it. FOCAL COGNITIVE DEFICITS AND DEPRESSION 123 TABLE 1 Neuropsychological Findings before and after Treatment of Depression Test 9 Months 7 Months Postoperative Postoperative WAIS (24) Verbal IQ 125 Not tested WAIS Performance IQ 89 85 Performance subtest raw scores Picture completion 16 15 Picture arrangement 14 14 Block design 25 24 Object assembly 22 21 Digit symbol 52 43 Block design: qualitative observations Broken configuration on 3/9 items, reversals Slow and deliberate, qualitatively normal Wechsler Memory Scale (23) Memory quotient 110 128 Memory subtest raw scores Information 6 6 Orientation 5 5 Mental control 9 9 Logical memory 12 115 Digit span 6 forward; 5 backward 7 forward; 6 backward Visual reproduction 8 13 Paired associate learning 19 21 Visual reproduction: qualitative observa- Loss of configuration; rotation, distortion Normal tions Clock drawing Numbers outside clock Normal Verbal delayed recall Verbal memory, 10-word list Wisconsin Card Sorting (8) Trail Making B (17) Hamilton depression rating (9) (retro- 7/10 items 10/10 items (alternate form) 9/10 by the fifth trial 10/10 by the second trial (alternate form) Normal Not tested Normal Not tested 21 3 spectively derived) Depression may accentuate the cognitive effects of a focal lesion by: a) superimposing additional cognitive deficits (3), b) impairing the capacity for sustained effort needed to compensate for the lesion (4), or c) directly impeding recovery of function by producing neurochemical alterations in the right hemisphere. Antidepressant drugs may alleviate the defects by reversing any of these three mechanisms. Our success with desipramine, a noradrenergic reuptake inhibitor, is particularly interesting in view of the work of Ro- binson and his colleagues (15, 18, 19) on experimental right hemisphere lesions. They demonstrated dis- turbed noradrenergic transmission and behavioral change following right hemispheric injury, both of which could be reversed with desipramine. The phenomenon reported here is clearly distinct from depressive pseudodementia (26) because at all times the patient continued to function at a high level occupation, and because his Verbal IQ while depressed was 125. Furthermore, the impaired performance on testing at 9 months cannot be attributed to lack of cooperation. When brain injury and depression occur in combi- nation, a definitive cognitive prognosis must await resolution of the depression. 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