Cognitive impairment in patients with depression is often overlooked because cognitive deficits and symptoms of depression often overlap. Understanding the neurobiological aspects of cognitive deficits is important, because cognition evolves as a therapeutic target in treating depression. Cognitive symptoms can precede or linger after symptoms of depression, such as sleep, appetite, and affective symptoms, improve. Emerging literature on medications targeting cognition in patients with depression should be considered when clinical decisions are made. Residual cognitive symptoms have been identified as a predictor of poor outcomes when treating depression. Referral to psychiatry should be considered in patients with residual symptoms where diagnosis is unclear.

CASE

Hilda is a 55-year-old married woman with 2 children in college. She is employed as an administrative assistant at a high school. She has been treated with sertraline for depression for the past year. She notes that her overall mood has improved, that she no longer feels hopeless, and that she is eating and sleeping fairly well. Hilda denies symptoms of anxiety and never experienced symptoms of mania. She drinks alcohol socially, “but never more than 2 drinks,” and denies other substance use. Results of routine laboratory evaluations and a complete yearly examination 3 months ago were normal. However, she indicates that she has trouble making decisions and that she has “brain fog,” which manifests as having trouble prioritizing and processing tasks at work. These symptoms were not present before her initial symptoms of depression began, and she has no prior psychiatric history. She thinks that her memory is “not as it used to be” and describes word-finding difficulty. She admits to missing her medications about once or twice a week. She worries that she will not be able to handle work responsibilities and that she has dementia. Typical symptoms of major depressive disorder (MDD) include feelings of sadness, helplessness or hopelessness, inappropriate guilt, loss of interest in previously enjoyable activities, sleep disturbances, decreased energy, appetite changes, psychomotor retardation or agitation, preoccupation with death or thoughts of suicide, and difficulty concentrating or making decisions. Any symptoms causing significant distress should be further addressed clinically.1 Other diagnoses, such as a medical condition (thyroid disorder or anemia) or bipolar spectrum, should be considered before diagnosing and treating depression conditions because treatment differs. Patients should be referred to psychiatry if symptoms warrant referral, such as patients who are resistant to treatment, or those experiencing psychotic symptoms, substance use, suicidality, or simply when the diagnosis is not clear. This report addresses the patient with MDD experiencing residual cognitive symptoms.