Flex Cog Ants y Desp D Depre

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Cognitive performance and subjective

complaints before and after remission
of major depression
a b c
Denise Lahr , Thomas Beblo & Wolfgang Hartje
a
Bethel Epilepsy Center , Mara Hospital, Rehabilitation Unit ,
Bielefeld, Germany
b
Clinic of Psychiatry and Psychotherapy Bethel , Bielefeld,
Germany
c
Department of Psychology , University of Bielefeld , Bielefeld,
Germany
Published online: 03 Feb 2007.
To cite this article: Denise Lahr , Thomas Beblo & Wolfgang Hartje (2007) Cognitive performance
and subjective complaints before and after remission of major depression, Cognitive
Neuropsychiatry, 12:1, 25-45, DOI: 10.1080/13546800600714791
To link to this article: http://dx.doi.org/10.1080/13546800600714791
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COGNITIVE NEUROPSYCHIATRY
2007, 12 (1), 25 45
Cognitive performance and subjective complaints before

and after remission of major depression
Denise Lahr
Mara Hospital, Rehabilitation Unit, Bethel Epilepsy Center, Bielefeld,
Germany
Thomas Beblo
Clinic of Psychiatry and Psychotherapy Bethel, Bielefeld, Germany
Wolfgang Hartje
Department of Psychology, University of Bielefeld, Bielefeld, Germany
Introduction . Patients with major depression report on severe cognitive deficits

but objective neuropsychological test results indicate rather mild problems. In the
present study we aimed at investigating neuropsychological performance, subjective
complaints, and observer ratings of cognitive abilities in everyday life.
Methods. Fifteen patients with major depression were studied in the acute state of
illness and after remission. Fifteen healthy control subjects were investigated, too. A
comprehensive neuropsychological battery, questionnaires for self and observer
rating of cognitive abilities, and clinical questionnaires were administered.
Results. As expected problems reported in self and observer ratings exceeded
neuropsychological deficits in tests. Neuropsychological test results tended to be
improved at the second test session, with patients showing a more pronounced
improvement in flexibility.
Conclusions. The data support the hypothesis that cognitive problems in everyday
life indeed exceed results in standardised tests. However, it seems also likely from
our data that results are additionally influenced by patients negative self perception.
Cognitive impairment is a major component of depressive disorders

(American Psychiatric Association, 1994). Patients report on cognitive
problems in everyday life (O’Connor, Pollitt, Roth, Brook, & Reiss, 1990)
and neuropsychological studies confirm the existence of impairments (Den
Hartog, Derix, van Bemmel, Kremer, & Jolles, 2003; Quraishi & Frangou,
Correspondence should be addressed to Denise Lahr, Mara Hospital, Rehabilitation Unit,

Bethel Epilepsy Center, Karl-Siebold-Weg 11, D-33617 Bielefeld, Germany. E-mail:
denise.lahr@evkb.de
# 2007 Psychology Press, an imprint of the Taylor & Francis Group, an informa business
http://www.psypress.com/cogneuropsychiatry DOI: 10.1080/13546800600714791
26 LAHR, BEBLO, HARTJE
2002; Shenal, Harrison, & Demaree, 2003). However, correlations between

subjective complaints and objective deficits are weak (Antikainen et al.,
2001; Barr, Rastogi, Ravdin, & Hilton, 1999; O’Connor et al., 1990)
and complaints tend to be more severe than deficits in neuropsychological
tests (Dentone & Insua, 1997). Actually, at least in younger patients with
major depression severe deficits have not been found: In a meta-analysis
Christensen, Griffiths, Mackinnon, and Jacomb (1997) reported moderate
deficits with an average effect size of 0.63 (slightly more than 0.5 SD
below the mean than /0.5 standard deviations) compared to healthy
controls. In a further meta-analysis (Veiel, 1997) most deficits in patients
with major depression also were not below /1 SD compared to the data
of healthy subjects. It is still unclear whether the discrepancy between
subjective complaints and neuropsychological data is due to the biased
self perception in depression. Correlations between complaints and self

reported depression (Barr et al., 1999; Dentone & Insua, 1997) argue for
this interpretation but since independent observer ratings of the
patients’ cognitive impairments are missing other factors can not be ruled
out, e.g., differences between neuropsychological settings and demands of
everyday life.
With regard to specific neuropsychological domains it is clear that
unipolar (Major Depression) and bipolar depressive patients (during the
depressive state) show deficits in executive functions, declarative memory
and attentional performance (Porter, Gallagher, Thompson, & Young, 2003;
Quraishi & Frangou, 2002) but a typical neuropsychological profile has not
has not yet been found: Some authors found prominent neuropsychological
deficits in executive functions (Beblo, Baumann, Bogerts, Wallesch, &
Herrmann, 1999; Fossati, Ergis, & Allilaire, 2002; Moreaud et al., 1996;
van Gorp & Cummings, 1996), whereas others primarily report on memory
deficits (Austin et al., 1992; Beats, Sahakian, & Levy, 1996; Elliott et al.,
1996) or cognitive slowing (Den Hartog et al., 2003). In agreement with these
heterogeneous neuropsychological results, structural and functional brain
abnormalities have been found in diverse brain areas such as the prefrontal
cortex, the temporal cortex including the hippocampus and amygdala, as
well as the basal ganglia and the cerebellum (Beblo & Lautenbacher, 2006;
Davidson, Pizzagalli, Nitschke, & Putnam, 2002). Mayberg (1997) postu-
lated a limbic cortico dysregulation with dorsal neocortical decreases and
ventral paralimbic increases, and a disturbance of the integrative function of
the rostral anterior cingulated cortex. Davidson et al. (2002) and Shenal,
Harrison, and Demaree (2003) acknowledged different inter- and intrahemi-
spheric dysfunctions in depression with specific behavioural consequences:
With regard to Davidson et al., a left-sided prefrontal hypoactivation would
result in deficits in pregoal attainment, whereas a right-sided hyperactivation
would result in excessive behavioural inhibition. Shenal et al. (2003)
TEST PERFORMANCE AND COMPLAINTS 27
postulated different neuropsychological deficits in depressive patients with

left frontal (e.g., sparsity of speech), right frontal (e.g., reduced attention),
and right posterior dysfunctions (e.g., impaired processing of emotional
stimuli).
In the course of depression cognitive deficits decrease with remission of
the depressive state, especially in young patients (Savard, Rey, & Post, 1980).
Primarily fluency functions seem to be closely related to the course
of depression (Beblo et al., 1999; de Groot, Nolen, Huijsman, & Bouvy,
1996; Porterfield, Cook, Deary, & Ebmeier, 1997; van Gorp & Cummings,
1996). It was also found that some deficits persist (Ferrier, Stanton, Kelly, &
Scott, 1999; Nebes et al., 2003; Paradiso, Lamberty, Garvey, & Robinson,
1997; Portella et al., 2003), but it is still a matter of debate which deficits
in which patients are still detectable after remission of the depressive
state.
The present study aimed, first, at an investigation of the neuropsycho-
logical profile of major depression. For this purpose we applied a
comprehensive series of cognitive tests in order to achieve a detailed and
representative assessment of performance covering the functional domains
of attention, memory and executive functions. Second, we tried to elaborate
the interrelationship existing between the patients’ subjective complaints
(self rating), the judgement of the patients’ condition by their relatives
(observer rating), and the results of the neuropsychological testing. To our
knowledge, the correlations between observer ratings on the one hand and
the patients’ self ratings and test performances on the other hand have not
systematically been taken into account in earlier research. The third
objective of the study was to trace the patients’ test performances and their
subjective complaints as well as the observer ratings of the patients’
condition across the course of remission, i.e., at the time of admission to
and at the time of discharge from the hospital.
It was expected, first, that in our group of young to middle-aged patients
(between 18 and 55 years) only mild and partial deficits would become
evident in neuropsychological test performances compared with healthy
subjects. Second, we expected that the subjective complaints of the patients
would markedly exceed their cognitive impairments demonstrated in
objective tests. Third, on the basis of these expectations, it was assumed
that a successful treatment with remission of depression should lead to a
significant improvement of the patients’ subjective complaints and that the
cognitive deficits observed in neuropsychological tests would be no longer
detectable. With respect to the relationship between the subjective com-
plaints and the rating of impairments by the patients’ relatives no particular
expectation could be derived from earlier studies.
METHOD
Participants
Thirty-one patients with major depression according to DSM-IV and 17
healthy control subjects were included in the study. All patients were
inpatients and selected from the Clinic of Psychiatry and Psychotherapy
Bethel. Healthy controls were collected by placards in doctors’ practices.
Exclusion criteria for participation in the study were acute suicidal tendency,
current or lifetime psychotic disorders, anorexia, substance abuse or
dependency, any personality disorder, serious anxiety disorder, neurological
disease, and severe somatic disorders possibly affecting the central nervous
system, e.g., cancer or diabetes. The age of all subjects was restricted to a
range of 1855 years. Additionally, the healthy subjects had no intake of any
CNS relevant drug and were mentally in health (no DSM-IV diagnosis).
Informed, written consent to participate in the study was obtained from all
subjects.
Of these subjects, 15 patients and 15 controls could be examined twice.
The drop-out of 16 patients was mainly due to organisational difficulties
(lack of information about the pending discharge). Two of the patients
refused a second examination. To equate the groups, the last two subjects of
the controls were excluded from the second examination.
Mean age of the patients was 38.1 years (range 2153 years), years of
basic school education were 10.6 on average. Eleven out of the fifteen
patients were women. With regard to these basic demographic variables the
healthy subjects were comparable with the patients (mean age 34.9; range
2051 years; mean education 11 years; nine women). Nine patients met the
criteria of the subtype ‘‘Melancholia’’and one patient showed atypical
symptoms. Six patients had a comorbid Specific Phobia, two patients a
Panic Disorder. Most patients received antidepressive medication (tricyclics:
n/7; selective serotonine reuptake inhibitors: n/2; noradrenaline seroto-
nine reuptake inhibitors: n /3; lithium: n /1) and four patients neuroleptics
(an atypical neuroleptic in one of these cases). Five patients received
benzodiazepines.
Procedure
Subjects were examined twice. The first examination of the patients took
place shortly after their admission to the clinic. This examination comprised
two sessions: On a first appointment, interviews and questionnaires
(described below) for clinical diagnosis, severity of depression, and self
ratings of the patients’ attentional and memory problems were administered.
In addition, the patients’ next of kin were asked to give observer ratings of
the patients’ attentional and memory problems. On a second appointment,

occurring within the next 4 days, the neuropsychological test battery
(described below) was applied. The neuropsychological tests were always
administered in the same order. The first examination of the healthy controls
was conducted in one session and included the same assessment procedures.
The date of the second examination of the patients was defined by the
remission of the depressive symptoms and was, therefore, planned to take
place shortly before the patients left the hospital, leading to intervals
between the two examinations from 3 weeks to 6 months. For the control
subjects, the interval between the two examinations was paralleled. For both
groups of subjects, the second examination comprised the same assessment
procedures as the first examination.
Materials
Interviews and questionnaires
For clinical diagnosis, participants completed the full Structured Clinical
Interview for DSM-IV (SCID; First et al., 1997; Wittchen, Zaudig, &
Fydrich, 1997).
The Beck Depression Inventory (BDI; Beck & Steer, 1994) was used for
the assessment of depressive symptoms.
The Questionnaire of Experienced Attention Deficits (Muller, Krause,
Schmidt, Munte, & Munt, 2004) was administered to assess self and
observer ratings of attentional deficits.
The Questionnaire of Memory Efficiency (Giovagnoli, Mascheroni, &
Avanzini, 1997) was used for the self and observer rating of everyday
memory problems. Relevant parameters of the questionnaire are provided in
Tables 2 and 3.
Neuropsychological tests
The selection of tests aimed at the inclusion of a broad array of different
neuropsychological functions relevant in depression (attention, memory,
executive functions). It was attempted to include psychometric tests similar
to those used in earlier studies concerned with neuropsychological deficits in
depression. All of the considered test parameters are defined in Table 1.
Attention. The Trail Making Test A (Reitan, 1992) was applied to assess
speed of spatial visual exploration. Subjects have to connect 25 numbers as
quickly as possible.
The Test d2 (Brickenkamp, 1994) was used to assess speed of visual
scanning and selective attention. In this cancellation task the letter ‘‘d’’,
which is marked by two small dashes in varying positions, has to be crossed

out among the distractor letters ‘‘d’’ and ‘‘p’’ marked in a similar way.
In addition, attention was assessed by means of the following subtests of
the computerised ‘‘Testbatterie zur Aufmerksamkeitspruefung’’ (TAP;
Zimmermann & Fimm, 1992): The subtest ‘‘alertness’’assesses simple
reaction time. The subject have to press a button as fast as possible when
a cross appeared on the screen. The cross is presented with (‘‘phasic
alertness’’) and without an auditive warning signal (‘‘tonic alertness’’). The
subtest ‘‘Go/no-go’’assesses response selection and response inhibition. Two
different crosses *one target, one distractor*were presented in random
order. The subjects have to respond to the target as quickly as possible. For
the assessment of divided attention, in the subtest ‘‘divided attention’’
subjects have to respond to visually and auditory presented targets.
Memory. Verbal memory was assessed by a German version of the

Auditory Verbal Learning Test (AVLT; Helmstaedter, Lendt, & Lux, 2001;
Rey, 1964). Subjects have to learn 15 words that are presented five times.
The Diagnosticum fuer Cerebralschaedigung (DCS; Weidlich & Lam-
berti, 2001) was administered for the assessment of nonverbal memory.
Subjects have to learn nine abstract figures that are presented six times.
Verbal working memory was assessed by a modified digit span task, the
Digit Suppression Test (DST; Beblo, Macek, Brinkers, Hartje, & Klaver,
2004). In the DST every second digit of a series of orally presented digits has
to be reproduced, beginning with the first digit.
Nonverbal working memory was assessed by a modified Corsi Block
Tapping Test, the Block Suppression Test (BST; Beblo et al., 2004). Subjects
are asked to reproduce only every second block of a series of blocks tapped
by the examiner, beginning with the first block.
Executive functions. Lexical verbal fluency was assessed by a task

requiring the subject to write as many words as possible with the initial
letters F, L, and R; 1 minute is given for each letter (LPS; Horn, 1983).
In the semantic verbal fluency task subjects have to name as many
animals as possible within 1 minute.
The figural fluency was examined by the Five Point Test (Regard, Strauss,
& Knapp, 1982). It consists of five-point matrices, and the subject is asked to
produce as many different patterns as possible within 3 minutes.
Cognitive flexibility was assessed by means of the Trail Making Test B
(TMT; Reitan, 1992) and by the computerised TAP (Zimmermann & Fimm,
1992) subtest Response Switching. The Trail Making Test B requires the
subject to trace the numbers from 1 to 13 and the letters from A to L in an
alternating matter. The TAP subtest Response Switching requires the subject
to alternate between letters and digits.
Statistical analysis
The data were analysed by analyses of variance (MANOVA, repeated
measurements). Spearman rank order coefficients were calculated for the
correlation between neuropsychological test scores and subjective ratings.
All levels of significance (p B/.05) reported in the following section are two-
tailed. For pairwise comparisons by univariate F-tests the alpha level was
adjusted according to the Bonferroni procedure. Although not all variables
were normally distributed, parametric stastitical tests were applied because
with equal sizes of the two samples and with n /10 the violation of the
assumption of normal distribution can be tolerated (Bortz, 2005). As a
precaution, nonparametric tests were also used for pairwise comparisons
with those variables that were not normally distributed; the results did not
differ from the corresponding parametric tests.
RESULTS
Neuropsychological tests
The results of all neuropsychological tests for both groups of subjects and
for both examinations (t1 and t2) are presented in Table 1. In the following,
for brevity and clarity, we restrict the detailed presentation to those results
that reached statistical significance.
Attention. For the purpose of multivariate analyses of attentional

performance the variables were grouped into three categories: alertness,
speed of processing in more complex attentional tasks, and accuracy
parameters of performance. Significant results were only obtained for the
four variables concerning speed of processing in complex tasks (go/no-go,
median reaction time; divided attention, median reaction time; Trail Making
Test A, time needed to complete the task; Test d2, number of scanned letters)
resulted in a significant main effect for time, F (1, 27) /4.76, pB/ .007 (o/
.44). This effect was due to an improvement of performance at the second
examination (t2) in the Test d2 total score only, F (1, 27) /21.38, MSE /
848.51, p B/ .001. Neither the main effect for group, F (1, 27) /2.08, nor the
interaction, F (1, 27) /0.70, reached significance.
Memory. For the purpose of multivariate analyses of memory perfor-

mance the variables were grouped into three categories: working memory,
immediate memory, learning and retention. None of the analyses yielded
significant effects.
32
TABLE 1
Results of the neuropsychological tests; confidence intervals are given for significant results
LAHR, BEBLO, HARTJE

Patients t1 Controls t1 Patients t2 Controls t2
(n /15) (n /15) (n /15) (n /15)
Function M SD M SD M SD M SD
Alertness
Alertness without warning signal reaction time (ms) 226.0 19.9 221.0 27.6 223.0 26.7 216.0 21.4
Alertness with warning signal reaction time (ms) 214.0 20.5 219.0 27.2 214.0 30.7 205.0 18.8
Speed of processing (attentional performance)
Go/no-go reaction time (ms) 378.0 43.8 393.0 52.2 385.0 64.9 375.0 53.1
Divided attention reaction time (ms) 681.0 60.0 659.0 60.4 691.0 95.6 645.0 103.0
Trail Making Test A (time to complete the task; s) 29.0 12.0 22.0 4.7 26.0 12.0 20.0 4.1
Test d2 (number of scanned letters) 427.0 76.7 502.0 66.2 462.0 99.9 538.0 72.9
Accuracy aspects of attentional performance
Go/no-go (number of errors) 1.3 1.3 0.5 1.0 0.4 1.1 0.9 0.9
Divided attention (omission errors) 1.4 1.3 1.1 1.3 1.4 1.6 1.1 2.1
Divided attention (number of false positive reactions) 0.9 1.4 1.1 1.8 0.8 0.8 1.2 1.9
Test d2 (errors) 21.4 14.3 16.7 10.0 15.4 11.9 14.0 13.3
Test d2 (fluctuation margin) 11.4 2.6 10.5 2.6 10.4 2.9 9.4 3.5
Working memory
Verbal working memory 5.0 1.7 6.9 1.9 5.8 1.8 6.5 1.6
Nonverbal working memory 3.9 1.2 5.4 2.3 4.7 1.8 5.7 2.0
Immediate memory
AVLT (number of recalled words after first presentation) 6.1 1.3 6.7 1.6 6.8 1.5 7.5 2.1
DCS (number of recalled figures after first presentation) 3.1 1.8 3.9 1.7 2.8 1.6 4.1 2.2
Learning and retention
AVLT (number of recalled words after fifth presentation) 13.0 1.9 14.4 1.0 13.3 1.6 13.7 1.8
Table 1 (Continued )

(n /15) (n /15) (n /15) (n /15)
Function M SD M SD M SD M SD
AVLT (number of recalled cumulated over the five runs) 50.9 7.2 56.9 6.2 54.8 5.5 57.5 9.3
AVLT (number of recalled words after interference list) 11.3 2.6 12.7 2.7 12.4 2.0 12.3 2.9
AVLT (number of recalled words after delay) 10.9 2.9 12.5 2.6 11.6 1.9 12.6 3.0
AVLT (number of correctly recognised words) 14.1 1.4 14.5 0.7 13.9 1.0 14.1 1.6
AVLT (false positive responses during recognition) 1.0 2.0 0.2 0.6 0.3 0.6 0.3 0.6
TEST PERFORMANCE AND COMPLAINTS

DCS (maximal number of correctly reproduced figures) 7.7 2.1 8.7 1.1 7.8 2.3 8.7 0.8
Speed of processing (flexibility)
Tap response switching reaction time (ms) 763.0 226.0 686.0 172.0 724.0 248.0 591.0 141.0
Trail Making Test B (time to complete the task; s) 69.5 23.4 54.0 14.3 52.2 15.0 53.3 15.7
Semantic verbal fluency (number of animals) 25.4 5.5 26.5 6.5 25.6 4.7 26.2 6.0
Lexical verbal fluency (number of words) 30.9 9.6 37.9 6.8 36.6 11.8 42.1 10.5
Figural fluency (number of correct patterns) 34.8 10.0 33.3 7.3 37.3 9.7 35.2 7.2
Accuracy aspects of cognitive flexibility
Tap response switching (errors) 2.1 2.3 2.9 2.1 1.9 1.8 2.5 2.7
Figural fluency (repetitions) 1.4 1.8 1.7 2.2 1.6 1.5 1.9 2.6
Confidence intervals
Trail Making Test B (time to complete the task; s) 57.3 94.9 46.1 61.9 41.3 78.5 44.6 62.0
Figural fluency (number of correct patterns) 23.7 35.5 34.1 41.7 25.2 41.1 36.3 47.9
33
Executive functions. For the purpose of multivariate analyses of execu-

tive functions the variables were grouped into two categories, both relating
to the flexibility of performance: speed of processing and accuracy
parameters of performance. Significant results were only obtained for speed
of processing.
The analysis for the aspect of speed of processing comprised five variables
(TAP response switching, median reaction time; Trail Making Test B, time
to complete the task; semantic verbal fluency, number of produced items;
lexical verbal fluency, number of produced items; figural fluency, number of
correct patterns). The results of the analysis showed a significant main effect
for time, F (1, 26) /15.00, p B/ .001 (o /.77), but no significant main effect
for group, F (1, 26) /1.13. The interaction was significant, F (1, 26) /2.76,
pB/ .05 (o /.39), and indicated a stronger improvement in the group of
patients compared to controls. Post hoc comparisons showed that this

interaction was due to an improvement of the patients, but not of the
controls, only in the time score of the Trail Making Test B, F (1, 26) /9.87,
MSE /97.84, pB/ .005. When the patients’ performances at the time of the
first assessment were compared with those of the controls a significant
difference emerged for the time score of the Trail Making Test B, F (1, 27) /
4.72, pB/ .04, and for the number of correct patterns produced in the Five
Point Test, F (1, 27) /5.10, p B/ .04. In both cases the patients performed less
well than the controls. At the second assessment no group comparison
reached significance (p -values/.10).
Results of the 16 patients who could not be tested twice

To make sure that the 16 patients who could not be tested twice were not
more impaired than the 15 patients remaining in the study these groups were
compared with respect to all dependent variables (demographic variables,
neuropsychological test performances, subjective ratings). None of these
comparisons yielded significant differences. In addition, we compared those
16 patients with the 15 controls with regard to the test performances at the
first assessment in order to verify the findings of significant performance
differences in the Trail Making Test B (time score) and the Five Point Test
(number of patterns) as reported above. Both comparisons were significant,
thus supporting the relevance of the findings. While the majority of the other
test scores did not differ between the groups, significant differences were
obtained for all scores of the AVLT, for the number of scanned letters in the
Test d2 and the score of the Trail Making Test A. This indicates that the 16
patients who did not participate in the second examination were slightly
more impaired.
Questionnaires
The results of the questionnaires for both groups of subjects and for both
examinations (t1 and t2) are presented in Tables 2 and 3.
An analysis of variance with the factors group (patients, controls), rater
(self, observer), and time (t1, t2) and with the cumulative Questionnaire of
Experienced Attention Deficits score as dependent variable revealed
significant main effects of group, F(1, 52) /46.11, p B/ .001 (o/.59), and
of time, F (1, 52) /31.68, p B/ .001 (o/.38), and a significant interaction
between group and time, F(1, 52) /35.57, pB/ .001 (o/.41) (Figure 1). No
other effects reached significance. The breaking-down of the Group /Time
interaction showed that only in the group of patients the Questionnaire of
Experienced Attention Deficits ratings improved from admission to
discharge, F (1, 13) /34.86, p B/ .001, but not in the group of controls, F (1,
14) /0.01. It should be noted that there was neither a significant main effect
of rater nor a significant interaction involving the factor of rater.
For the Questionnaire of Memory Efficiency similar analyses of variance
were conducted for the cumulative score as well as for four of the sum scores
(short-term memory, long-term memory, remote memory, prospective
memory). Regarding the cumulative score, the analysis revealed significant
main effects of group, F (1, 53) /49.77, p B/ .001 (o/.48), and of time, F (1,
53) /15.46, p B/ .001 (o/.23). These main effects were modified by
significant interactions between group and time, F (1, 53) /6.10, pB/ .02
(o/.10), and between rater and time, F (1, 53) /5.81, pB/ .02 (o /.10). The
pattern of main effects and interactions is illustrated in Figure 2. The
Group /Time interaction could be traced back to a significant improvement
of self rating in the group of patients only, F (1, 14) /16.79, MSE /0.07, p B/
.002. Neither the observer rating in the group of patients, F (1, 10) /1.22,
MSE /0.056, nor the two ratings in the group of controls: self rating, F (1,
14) /1.89, MSE /0.04; observer rating, F (1, 14) /0.17, MSE /0.017,
showed any significant improvement over time. The Rater /Time interac-
tion was due to the fact that the patients rated their impairment as
significantly higher than their relatives at the first assessment, F (1, 26) /
9.96, pB/ .004, while this difference was no longer significant at the second
assessment, F (1, 26) /0.31. In the group of controls there was no significant
difference of any kind (all p-values /.20). The significant main effect of
group was due to the fact that the ratings in the group of patients reflected a
stronger impairment than those in the group of controls at both times: self
rating at t1, F(1, 30) /50.05, pB/ .001; self rating at t2, F (1, 30) /23.73, p B/
.001; observer rating at t1, F (1, 29) /18.32, p B/ .001; observer rating at t2,
F (1, 26) /49.77, pB/ .004. The significant main effect of time was exclusively
due to the improvement of the self rating in the group of patients, F (1, 14) /
16.79, MSE /0.07, p B/ .002, while neither the observer rating in the group
36
TABLE 2
Self ratings in the questionnaire of experienced attention deficits, the questionnaire of memory efficiency and the BDI; confidence intervals
are given for significant results
LAHR, BEBLO, HARTJE

(n /14) (n /15) (n /14) (n /15)
Scale M SD M SD M SD M SD
Questionnaire of Experienced Attention Deficits (n /14)

Cumulative score 3.51 0.83 1.70 0.38 2.50 0.81 1.71 0.31
Questionnaire of Memory Efficiency
Short-term memory 2.81 0.52 1.77 0.37 2.38 0.49 1.65 0.27
Long-term memory 3.20 0.55 1.93 0.44 2.63 0.64 1.85 0.33
Remote memory 2.10 0.81 1.35 0.45 1.78 0.57 1.43 0.35
Prospective memory 2.42 0.65 1.96 0.58 2.39 0.70 2.00 0.49
BDI (n /15 patients and controls)
Confidence intervals
Questionnaire of Experienced Attention Deficits
Long-term memory 2.90 3.50 1.69 2.18 2.27 2.98 1.67 2.04
Remote memory 1.65 2.55 1.10 1.60 1.47 2.10 1.24 1.63
BDI (n /15 patients and controls)
TABLE 3
Observer ratings in the questionnaire of experienced attention deficits and the questionnaire of memory efficiency

(n /12) (n/15) v(n /12) (n /15)
TEST PERFORMANCE AND COMPLAINTS

Scale M SD M SD M SD M SD
Questionnaire of Experienced Attention Deficits (n /12)

Long-term memory 2.58 0.67 1.72 0.54 2.36 0.50 1.72 0.50
Remote memory 1.66 0.61 1.28 0.38 1.59 0.50 1.23 0.32
37
4,5
3,5
3
sum score
self-rating patients
self-rating controls
2,5
observer-rating patients
2 observer-rating controls
1,5
1
0,5
0
t1 t2
Figure 1. Subjective complaints and observer ratings of patients and healthy controls with regard to
attention.
4,5
3,5
3
sum score
self-rating patients
self-rating controls
2,5
observer-rating patients
2 observer-rating controls
1,5
0,5
0
t1 t2
Figure 2. Subjective complaints and observer ratings of patients and healthy controls with regard to
memory.
of patients, F (1, 10) /1.22, MSE /0.06, nor the two ratings in the group of
controls: self rating, F (1, 14) /1.89, MSE /0.04; observer rating, F (1, 14) /
0.17, MSE /0.02, showed any significant change over time.
Concerning the short-term memory score the analysis resulted in
significant main effects of group, F(1, 53) /52.32, p B/ .001 (o/.50), and
time, F (1, 53) /11.58, pB/ .002 (o /.18), and a significant interaction
between these factors, F (1, 53) /4.19, pB/ .05 (o /.10). No other effects
reached significance. The Group /Time interaction was due to an improve-
ment from t1 to t2 of the self rating in the group of patients: self rating, F (1,
14) /7.98, MSE /0.17, p B/ .02; observer rating, F (1, 10) /1.64, MSE /
0.17, while there was no such improvement in the controls: self rating,
F (1, 14) /2.00, MSE /0.05; observer rating, F (1, 14) /0.77, MSE /0.01.
For the long-term memory score the analysis revealed significant main
effects of group, F(1, 53) /45.38, p B/ .001 (o/.46), time, F (1, 53) /9.76,
pB/ .005 (o/.16), and rater, F (1, 53) /7.38, pB/ .01 (o /.12), and a
significant interaction between group and time, F (1, 53) /6.44, pB/ .02
(o/.11). No other interaction term reached significance. The Group /Time
interaction was due to a significant improvement of the self rating score in
the group of patients: self rating, F (1, 14) /11.37, MSE /0.22, pB/ .006;
observer rating, F (1, 10) /2.38, MSE /0.11, while no improvement was
observed in the group of controls: self rating, F (1, 14) /0.65, MSE /0.07;
observer rating, F (1, 14) /0.00, MSE /0.07. Apart from this interaction
effect, the self ratings of deficits were higher than the observer ratings (p B/
.05).
Relating to the remote memory score the analysis resulted in a significant
main effect of group, F (1, 53) /11.48, p B/ .002 (o /.18). No other effects
reached significance. The main effect indicated a generally better rating in
the group of controls.
Likewise, the analysis of the prospective memory score showed only a
significant main effect of group, F (1, 52)/7.57, p B/ .01 (o /.18), indicating
a generally better self and observer rating in the group of controls than in the
group of patients, with no other significant effects.
The general pattern of effects observed with regard to the single sum
scores of the Questionnaire of Memory Efficiency resembles the pattern
found for the cumulative score. That is, the patients themselves rated their
memory deficits as high at the first assessment, with considerable improve-
ment at the second assessment. Although their relatives also recognised
deficits, their ratings indicated less severe impairments and showed no
significant improvement over time. As was to be expected, the controls and
their next of kin reported no essential deficits and no change over time.
The analysis of variance for the cumulative BDI score showed significant
main effects for group, F (1, 27) /67.50, pB/ .001 (o /.71), and time, F (1,
27) /22.49, p B/ .001 (o /.45), and a significant interaction between these
factors, F (1, 27) /17.75, p B/ .001 (o /.40). The interaction was due to the
fact that the patients improved considerably from t1 to t2, T (1, 14) /4.55,
pB/ .001, while there was no improvement for the controls, T (1, 14) /1.13,
p/ .20. Patients were significantly more depressive than controls at t1
and t2.
Correlations between questionnaires and test scores in the group

of patients
At the time of the first assessment only a few correlations between
questionnaires and test scores reached significance. Moderately high
coefficients were obtained for the correlation between the Questionnaire of
Experienced Attention Deficits self rating cumulative score and the error
score of the Test d2, r / /.37, p B/ .05, as well as for the correlation between
the cumulative score of the Questionnaire of Memory Efficiency and the
recognition score of the AVLT, r / /.37, pB/ .05. In addition, the self rating
of short-term memory correlated significantly with the number of words
recalled after the first presentation of the AVLT word list, r / /.48, pB/ .01,
and with the total number of words recalled across the five word list
presentations, r / /.43, p B/ .02. The observer ratings in the Questionnaire
of Experienced Attention Deficits cumulative score correlated significantly
only with the error score in the Test d2, r/ /.46, pB/ .05. The observer
ratings in the Questionnaire of Memory Efficiency correlated with none of
the neuropsychological test performances.
At the time of the second assessment the Questionnaire of Experienced
Attention Deficits score showed a significant correlation with the reaction
time in the divided attention subtest, r /.67, p B/ .01. Likewise, the
cumulative score of the Questionnaire of Memory Efficiency correlated
significantly with verbal and nonverbal working memory, r / /.53, pB/ .05;
r/ /.58, pB/ .05. The observer ratings in the Questionnaire of Experienced
Attention Deficits cumulative score correlated significantly with the number
of words recalled after the fifth presentation of the list, r/ /.65, pB/ .03,
and with the number of correctly recalled words cumulated over the five
runs, r/ /.70, pB/ .02, and with the number of words correctly recalled
after presentation of the interference list, r/ /.83, p B/ .002. The observer
ratings in the Questionnaire of Memory Efficiency correlated with none of
the neuropsychological test performances.
Of all correlations between the self ratings and observer ratings only the
correlation related to the prospective memory at the second assessment was
significant, r/.63, p B/ .04.
DISCUSSION
At the time of the first assessment following admission to the hospital our
patients showed highly pronounced subjective complaints concerning
performance deficits in memory and attention, in addition to the general
symptoms of depression. The average self ratings of their attentional and
memory performance were two to four standard deviations below the mean
of the controls. Significant deficits related to attentional and memory
performance of the patients were also reported by the patients’ next of kin,
although to a much lesser degree.
By contrast, neuropsychological testing revealed only inefficiencies in
processing, and this only in a few variables. Thus, at the time of admission,
the patients performed less well than the controls only in the time score of
the Trail Making Test B and in the number of patterns produced in the Five
Point Test. The vast majority of the patients’ test performances were less
than one standard deviation below the mean of the controls. The finding
that the patients’ performances in the Trail Making Test B and the Five
Point Test differed significantly from the performances of the controls
suggests that tests of executive functions might be particularly sensitive to
the kinds of potential cognitive problems associated with depression.
Unfortunately, because our selection of executive tasks did not include
more complex tests of planning abilitity as, e.g., the Behavioral Assessment
of Executive Syndrome (BADS), our results do not allow any further
conclusions with regard to this possibility.
The correlation between the subjective complaints of the patients and the
neuropsychological test performances was generally low. In the realm of
attentional functions only the correlation between the Questionnaire of
Experienced Attention Deficits cumulative self rating score and the error
score of the Test d2 reached significance. With regard to memory functions
there were only three significant correlations: the cumulative self rating score
of the Questionnaire of Memory Efficiency correlated with the recognition
score of the AVLT, and the self rating of short-term memory correlated with
the number of words recalled after the first presentation of the AVLT word
list and with the total number of words recalled across the five list
presentations.
The results of our study thus support the findings of Christensen et al.
(1997) and Veiel (1997) that younger patients with major depression do not
differ markedly from healthy controls in neuropsychological test perfor-
mances. They also confirm the findings of Dentone and Insua (1997) that the
subjective complaints tend to be more severe than the deficits observed in
neuropsychological tests. Further, the fact that significant correlations
between subjective complaints and neuropsychological test performances
were rare and generally weak in our group of patients corresponds to the
findings of Antikainen et al. (2001), Barr et al. (1999), and O’Connor et al.
(1990).
Summing up so far, the attempt to find a profile of neuropsychological
deficits that might be regarded as typical for patients with major depression
was not successful, although a rather comprehensive battery of cognitive
tests was applied in the present study. The failure to find a characteristic
profile is due to the fact that even markedly depressive patients perform
more or less normally on psychometric tests *notwithstanding the severe
subjective complaints about cognitive performance deficits of these same
patients. Further, due to the small sample size, a systematic analysis of the
impact of medication was impossible. Thus, it cannot be ruled out that the
psychotropic medication has influenced the results.
It is interesting to note that the patients’ subjective complaints about
deficits of attention and memory improved considerably from the time of

admission to the time of discharge while the controls showed no such
change. However, even at the time of discharge the patients still considered
themselves as somewhat impaired in attentional and memory functions (and
still rated themselves as slightly depressed in the Beck Depression
Inventory). These findings are contrasted by the fact that concerning the
neuropsychological test performances there were almost no significant
interactions between group and time. Only in the field of executive functions
a significant Group /Time interaction emerged. This interaction could be
traced back to a more pronounced improvement of the patients compared to
the controls in one single variable, i.e., the speed score of the Trail Making
Test B. This indicates that the remission of major depression had almost no
particular effect on the psychometric test performance of the patients.
These findings raise the question of how to explain the discrepancy
between the striking subjective complaints of the patients and their almost
normal cognitive test performances. One possible explanation relates to a
biased self perception of depressive patients. This argumentation is
supported by a stronger deficit in self rated memory compared to observer
ratings and generally weak correlations between self and observer ratings.
Also, the fact, that differences between self and observer ratings decrease in
the course of treatment support this interpretation.
Alternatively, the observed discrepancy could be due to an essential
difference between the requirements of neuropsychological testing and the
demands of everyday life. That is, the presentation of a well circumscribed
task in the highly structured context of a neuropsychological examination,
where all disturbing and distracting influences are excluded and where the
subject’s performance is continuously monitored by the examiner, enables
the patient to perform almost normally. In contrast, tasks of everyday life
are much less structured and frequently more complex than psychometric
tests. They have often to be self organised and self paced and are susceptible
to various kinds of disturbances and distractions. Also, these tasks allow the
patients to distract their thoughts of the task at hand. Similar results
between self and observer ratings with regard to attention and the fact that
deficits observed by relatives exceed neuropsychological test results support
this hypothesis.
However, these conclusions must be regarded as tentative since we have
not included validating measures, e.g., a measure of insight to judge the
biased self perception in the sample of depressed patients. Furthermore, the
conclusions base on the assumption that the observer ratings are more or
less ‘‘objective’’. However, it seems likely that the ratings of the patients’
relatives are influenced by the patients complaints and that these
ratings,therefore, are not independent of the patients’ self perception.
Another weakness of the presented study concerns the small sample size,
making the disclosure of significant relations difficult. Especially in the

context of the broad aims of the present study this point clearly limits our
conclusions. Future research is needed comprising more objective observer
measures and measures of insight.
In sum, it seems plausible from our data that cognitive problems of
depressive patients in everyday life indeed exceed results in standardised
tests. This effect may be increased in self ratings due to a negative self
perception of depressed patients. Future research is needed comprising more
objective observer measures and measures of insight. It might be a promising
approach in future research to directly confront the patients with the
demands of their everyday life or professional activities and to observe their
performance in these situations.
Manuscript received 8 July 2005
Revised manuscript received 5 December 2005
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Cognitive performance and subjective

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Cognitive performance and subjective complaints before

Introduction . Patients with major depression report on severe cognitive deficits

Cognitive impairment is a major component of depressive disorders

Correspondence should be addressed to Denise Lahr, Mara Hospital, Rehabilitation Unit,

2002; Shenal, Harrison, & Demaree, 2003). However, correlations between

self perception in depression. Correlations between complaints and self

postulated different neuropsychological deficits in depressive patients with

the patients’ attentional and memory problems. On a second appointment,

which is marked by two small dashes in varying positions, has to be crossed

Memory. Verbal memory was assessed by a German version of the

Executive functions. Lexical verbal fluency was assessed by a task

differ from the corresponding parametric tests.

Attention. For the purpose of multivariate analyses of attentional

Memory. For the purpose of multivariate analyses of memory perfor-

LAHR, BEBLO, HARTJE

(n /15) (n /15) (n /15) (n /15)

Patients t1 Controls t1 Patients t2 Controls t2

TEST PERFORMANCE AND COMPLAINTS

Executive functions. For the purpose of multivariate analyses of execu-

patients compared to controls. Post hoc comparisons showed that this

Results of the 16 patients who could not be tested twice

LAHR, BEBLO, HARTJE

(n /14) (n /15) (n /14) (n /15)

Questionnaire of Experienced Attention Deficits (n /14)

Patients t1 Controls t1 Patients t2 Controls t2

TEST PERFORMANCE AND COMPLAINTS

Questionnaire of Experienced Attention Deficits (n /12)

Correlations between questionnaires and test scores in the group

deficits of attention and memory improved considerably from the time of

making the disclosure of significant relations difficult. Especially in the

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