August 6, 2019

Everything about cognitive rehabilitation in depression

According to the World Health Organization (WHO), depression affects more than 300 million people in the world, being considered a frequent mental disorder. The emotional symptoms are usually the first to be treated with current existing treatments, but how can we intervene on the cognitive impairment that often affects the people that suffer from depression?

In a recent scientific study carried out in a population with Major Depressive Disorder (MDD) (Escolano, 2014) a new cognitive rehabilitation neurotechnology was proven effective, with 20% improvement in functions such as working memory, sustained attention and processing speed.

What is depression?

Depression is a very frequent mental disorder that can start at any age, and in more severe cases can even lead to suicide. Although the probability of suffering from this disorder increases with puberty, the average age at onset is around 35 years of age, with higher prevalence in women. 

Duration of the depressive episodes is highly variable and, although most people recover in one or two years, approximately 15% present a chronic course. This chronic course is related to other mental disorders such as personality disorders, anxiety disorders or substance use.

Six stages can be identified in the course of depressive disorders:

  • Response to treatment: severity of symptoms reduces in more than 50% in comparison with the initial levels of the disorder.

  • Partial remission: some symptoms continue to manifest but very mildly. The depression diagnosis criteria are not fulfilled and more than two months have passed since the last episode.

  • Total remission: symptoms have disappeared during at least the last two months.

  • Recovery:  remission is maintained during more than six months, and normal functionality is recovered. 

  • Relapse: depressive symptoms reappear during the remission period.

  • Recurrence: new episode of depressive symptoms.

What are the symptoms of depression?

Although the most representative symptom of depression is sadness, it could be accompanied by mood, motivational, behavioral, cognitive, physical or interpersonal symptoms. Therefore, the depressive symptomatology can be classified into:

  • Mood-related symptoms: sadness, irritation, numbness, emptiness, anxiety, etc.

  • Motivational and behavioral symptoms: anhedonia (reduced motivation or ability to experience pleasure), apathy, abulia (lack of will or energy to do something), psychomotor delay, behavior inhibition, etc.

  • Cognitive symptoms: important difficulties in executive functions and cognitive capabilities such as memory, attention, concentration, processing speed, cognitive distortions, thoughts of uselessness and guilt, etc.

  • Physical symptoms: alterations in sleep and appetite, inhibited sexual drive, headaches, nausea, vomits, gastrointestinal discomfort, etc.

  • Interpersonal symptoms: deteriorated interpersonal relationships produced, in many cases, by the rejection generated in others towards the people who suffer from depression, due to their multiple complaints and lack of motivation.

Focusing on the cognitive symptoms, the first cognitive capabilities and executive functions to deteriorate in people with depression are:

  • Attention: capacity of generating, selecting, directing and maintaining an adequate activation level to process relevant information.

  • Processing speed: capability that establishes a relationship between cognitive execution and invested time. Enables the processing of information in a fast and automatic manner.

  • Learning: relatively stable transformations in behavior, elicited by different experiences that originate new knowledge and abilities.

  • Memory: registers, stores and elicits different experiences, which could be ideas, images, events, etc.

  • Reasoning: capability to solve problems, extract conclusions and learn in a conscious manner from events, in such a way that we can establish causal and logical relations. 

infografia-capacidades-cognitivas.jpg

What causes depression?

There are multiple factors that cause depression; genetics is one of the most important factors but it is not the only as biochemical, personal or environmental factors can intervene.

  • Genetic factors: these play an important role in the emergence of depression, as it has been demonstrated that the probability of developing this illness is 25-30% higher if there is family history (parents, siblings). Moreover, different studies have demonstrated that in monozygotic twins (who originate from a single fertilized egg), the probability that one twin suffers from depression is 50% higher if the other twin has the disorder. In dizygotic twins, this probability decreases to 25%.

  • Biochemical factors: depression is associated with different neurotransmitters, biomolecules that enable the transmission of information from one neuron to another. Among the different neurotransmitters, people who suffer from depression present a functional deficiency in noradrenaline. Low levels of serotonin are also related to the emergence and chronification of this disorder.

  • Endocrine factors: the hypothalamic–pituitary–adrenal axis (HPA axis) has been related to depression, as an increase in the secretion of cortisol has been observed together with depression. Another association has been established with the hypothalamic–pituitary–thyroid axis, as it has been demonstrated that people with hyperthyroidism are more inclined to be depressed, and vice-versa. Alterations in growth hormone secretion have also been found in those with depression.

  • Structural and neuropsychological factors: an unbalance in the brain activity of both hemispheres has been established after electroencephalogram (EEG) studies. Depressed individuals present lower electroencephalogram activity in the left hemisphere, and higher in the right hemisphere. Moreover, it has been verified that depressed individuals present reduced activity in the anterior cingulate cortex, smaller hippocampal volume, and higher activation of the tonsils.

  • Socio-demographic factors: age is an important factor for the onset of depression. Between 35 and 45 years of age, the incidence of this pathology is higher. However, depression also occurs in younger individuals, affecting especially affecting teenagers, age at which significant changes occur at hormonal and physical levels. Gender is also an influencing factor; women present higher prevalence with two critical periods during which these differences increase: during pregnancy and post-partum, moments with significant hormonal changes.

  • Environmental factors: work-related problems, difficult economic situations, family disagreements, substance use, among others, are factors that can produce stress and result in the development of depressive disorder. Moreover, many of these situations of daily life favor isolation and miscommunication, hindering communication with others, which potentialize the influence of these triggering factors.

How is depression treated?

There are different treatments that have been demonstrated effective for depression. On one hand, the most known are the antidepressants, pharmacological treatments frequently prescribed for an immediate reduction of the symptoms. On the other, psychological therapies reduce symptoms and maintain improvements at the long term, avoiding the secondary effects of the drugs. Before prescribing any treatment it is important to undergo a complete neuropsychological assessment, which will provide valuable data that will help decide the most adequate type of treatment for each case.

Drugs are the most prescribed treatment for depression, despite of the secondary effects. Selective serotonin reuptake inhibitors are usually utilized to improve symptoms and reduce the secondary effects, in comparison with other drugs. Tricyclic antidepressants are also utilized, along with dual inhibitors of the reuptake of serotonin and noradrenaline, and reversible inhibitors of monoamine oxidase. 

Psychological treatment, among which the cognitive-behavioral therapy stands out, has also demonstrated its effectiveness for depression. Those therapies frequently employed include: 

  • Cognitive-behavioral therapy: These therapies usually start working on the behavioral side to recover the functionality levels that existed before the disorder. Once positive results are obtained in those symptoms, which are more visible and objective, it is easier to start working on the cognitive aspects. These include interventions on automatic negative thoughts, distortions and cognitive biases that are the central nucleus of depression.

  • Interpersonal therapy: encompasses the depression associated with difficulties and problems in interpersonal relationships. When these problems escalate and there are no specific strategies to address them, relationships with others become even more difficult, creating a vicious circle.

  • Behavioral activation therapy: considers as key characteristic the lack of activity of the depressed individuals, as well as their lack of initiative and motivation. Intervening on these aspects through learning and reinforcement procedures, the person gradually recovers his/her previous level of activity, carrying out tasks that are gratifying, improving her/his state of mind and negative thoughts.

  • Problem solving therapy: this therapy has the objective of providing  coping strategies to people with depression, so that they can solve their daily life problems by themselves. T his type of therapy is oriented towards changing the way people perceive and address their problems, tackling them as challenges and improving their self-esteem and self-efficacy..

Focusing on cognitive deterioration, one of the symptoms of depression that has great repercussion at functional, personal, interpersonal and occupational levels, there are different strategies oriented to neuropsychological rehabilitation. Usual routines, such as exercising regularly, maintaining a balanced diet, bedtime schedule, close social support network, and mental activation through techniques and exercises for cognitive stimulation are fundamental to help revert the symptoms of deterioration.

How to cognitively rehabilitate a person with depression? 

Despite the positive effects of the different treatments for depression, these have not sufficiently approached the effects on the symptoms of cognitive decline. For such, there are different neuropsychological rehabilitation strategies that help recover and stimulate the deteriorated cognitive functions.

These alterations can be addressed by different resources, from the classic cognitive stimulation exercise workbooks to advanced technologies that have the objective of rehabilitating the altered cognitive capabilities.

A classic cognitive stimulation therapy is based on exercise workbooks for cognitive stimulation in depression that work on executive functions and capabilities such as memory, attention, orientation, reasoning, problem solving, etc. 

These are easy to find in bookstores and on the internet. Usually, these cognitive stimulation workbooks are available in different levels of difficulty, so that they can be used by people with different levels of deterioration. 

It is important to adapt the difficulty to the level of cognitive deterioration presented by the individual, so that they do not end up attempting to finish tasks that require great effort and they do not know how to solve. This can aggravate their bad mood and reinforce self-contempt and uselessness feelings towards themselves.

Another cognitive stimulation type includes the brain training games. These applications, available for smartphones, computers and tablets, can be employed anywhere, anytime. These games help people with depression to work on those cognitive capabilities that are deteriorated. There are different difficulty levels to choose from, so that the games can be adjusted to the cognitive deterioration level of the user. 

Although widely employed as cognitive stimulation tools nowadays, a limiting factor is the lack of evidence on the transference of the learning to cognitively close and daily life tasks (read more about the subject in the prestigious Nature journal).

A classic technology for the treatment of cognitive effects of major depression is transcranial electrical stimulation, which is based on low-intensity electrical currents that stimulate the neurons of the patients. In the context of cognitive improvement in depression, a recent meta-study documents an absence of effectiveness. However, there are many applications in which this technique is being successfully applied, such as treatment of migraines, Parkinson's disease, and schizophrenia. It is also being utilized as a research tool to help understand brain functions, with good results.

Neurotechnology is also based on cognitive stimulation and is attracting attention and becoming more and more popular. These new technologies register the brain activity of each person and adapts, in an individual manner, the required interventions to produce changes in brain neuroplasticity. These changes are related to rehabilitation and improvement of cognitive capabilities such as attention, memory and processing speed. 

Some studies have demonstrated their efficacy in general populations as well as in clinical populations, such as in those with major depression and ADHD. In this context, Elevvo Medical, developed by Bitbrain, is a neurotechnology for the cognitive rehabilitation of patients that suffer from illnesses that include cognitive deterioration or decline. More information on cognitive stimulation for children with ADHD. Another population, such as older adults with Alzheimer's disease or people with dementia, may also be able to obtain benefits from these types of techniques.

Neurotechnology for cognitive stimulation in depression 

Many times, cognitive deterioration appears among the symptoms of depression, and can interfere with the development of daily life activities. Interventions addressing these changes and rehabilitation of the executive functions and cognitive capabilities that are deteriorated is very important, and can improve the wellbeing levels, helping minimize emotional symptoms. Cognitive rehabilitation programs such as Elevvo can help in the improvement of these altered cognitive capabilities.

paciente con depresión que realiza rehabilitación paciente con depresión que realiza rehabilitación cognitva para mejorar sus funciones ejecutivas al entrenar el cerebro

Elevvo is a cognitive rehabilitation program that has been scientifically validated in different populations and employed to complement other conventional treatments. Bitbrain carried out a study in collaboration with the Hospital Miguel Servet, the Instituto Aragonés de Ciencias de la Salud (IACS) and Universidad de Zaragoza (Escolano, 2014) encompassing people diagnosed with Major Depressive Disorder. This study compared an experimental group (diagnosed with depression) that underwent eight cognitive rehabilitation sessions with Elevvo against a control group (who did not use Elevvo). 

The main result at cognitive level was a significant increment, verified only in the experimental group, in the PASAT test variables (attention, memory, processing speed). Besides, they commited 24% less mistakes and required 15% less time to complete the test. This suggests that the cognitive symptoms of patients with depression could be alleviated with this type of procedure.

These Elevvo programs have demonstrated improvements between 10% and 30% in working memory, sustained attention and processing speed, and are applied by professionals that help the patient carry out a series of simple cognitive trainings. Several sessions of cognitive rehabilitation are included, along with two assessment sessions (before and after the training) that help generate a comparative report that includes neuroplastic changes (which are the neurophysiological support of cognitive improvement) and cognitive changes.

results report of cognitive depression stimulation therapy in depression

 

Depression is a very frequent mental disorder that affects several areas of the life of people. It is clear that the most evident symptoms are the emotional ones, but there are other important symptoms such as cognitive deterioration, which many times are neglected at the time of searching for treatment. With the help of new technologies, there are several programs for the cognitive neuropsychological rehabilitation of the most deteriorated capabilities. 

These techniques, together with other psychiatric and psychological therapies are key tools to revert symptoms, recover from the disease and improve the quality of life. 

Carlos Escolano, et al. “A controlled study on the cognitive effect of alpha neurofeedback training in patients with major depressive disorder”. Frontiers of Behavioral Neuroscience., 02 September 2014.

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Infographic cognitive capabilities PDF