DEPRESSION
AND
ANXIETY 0:1–5 (2007)
Research Article
DO MEMORY COMPLAINTS REPRESENT IMPAIRED
MEMORY PERFORMANCE IN PATIENTS WITH MAJOR
DEPRESSIVE DISORDER?
Arash Mowla, M.D., Hamid Ashkani, M.D., Ahmad Ghanizadeh, M.D., Gholam Reza Dehbozorgi, M.S.,
Behnam Sabayan, M.D., and Abdul Hamid Chohedri, M.D.
Memory complaints are found to be associated with depression. However, the
question is, ‘‘How much these subjective complaints indicate objective memory
impairments?’’ The aim of this study is to determine whether subjective memory
complaints represent objective memory impairments and to establish the
demographic and clinical characteristics of patients with major depressive
disorder (MDD) and subjective memory complaints. Sixty-four patients with
MDD were assessed for objective memory performance through subtests of the
Wechsler Memory Scale-III. Memory complaints also were assessed in these
patients with a structured interview. Thirty healthy controls were also included
in the study to compare memory performance among groups. The Hamilton
Rating Scale for Depression was used to measure the severity and characteristics
of depression. Patients with MDD who had longer duration and earlier onset of
depression reported more memory complaints. MDD patients with memory
complaints had more hypochondriac concerns but not more depression severity
compared with those without memory complaints. There was no relationship
between subjective memory complaints and objective memory performance in
MDD patients. Patients with MDD with and without memory complaints had
lower scores on the Wechsler Memory Scale-III than the control group.
Subjective memory complaints are not a valid indictor of objective memory
impairments, and the diagnostic value of self-reported memory is being
questioned in patients with MDD. The cognitive status of MDD patients should
be assessed routinely, regardless of the patient awareness of his or her cognitive
deficits. Depression and Anxiety 0:1– 5, 2007.
& 2007 Wiley-Liss, Inc.
Key words: memory; cognition; depression; hypochondriac; psychiatric
Little
INTRODUCTION
information exists about the relationship
between subjective complaints of memory and
objective memory performance in patients with major
depressive disorder (MDD). If subjective memory
complaints indicate objective memory deficits, then
these complaints should be taken more seriously
as memory disorders.
The relationship between self-reported cognitive
functioning
and
psychometric
neurocognitive
performance has been reported to be poor in
psychiatric patients [Moritz et al., 2004], whereas
self-reported cognitive complaints were strongly asso-
r 2007 Wiley-Liss, Inc.
ciated with depressive symptomatology in different
psychiatric disorders [Chamelian and Feinstein, 2006;
Department of Psychiatry, Shiraz University of Medical
Sciences, Shiraz, Iran
Correspondence to: Arash Mowla, Department of Psychiatry,
Hafez Hospital, Shiraz University of Medical Sciences, Shiraz,
Iran. E-mail: [email protected]
Received for publication 3 November 2006; Revised 30 April 2007;
Accepted 1 May 2007
DOI 10.1002/da.20343
Published online in Wiley InterScience (www.interscience.wiley.
com).
2
Mowla et al.
Derouesne et al., 1999; Reid and Maclullich, 2006].
Depressed patients have a negative view toward
the self, the world and the future, so their poor
memory perception also may stem from this negative
cognition [Beck et al., 1979]. There are several studies
that have found no association between symptoms of
depression and neuropsychological or psychomotor
performance [Rohling et al., 2002; Tsushima et al.,
2005]. Hanninen et al. [1994] found that people who
complained about their memory had more somatic
complaints as well as more negative feelings about
their own competence and capabilities. In the elderly,
those with higher memory complaints had higher
scores for neuroticism than those who did not have
complaints [Reid and Maclullich, 2006]. Comijs et al.
[2002] concluded that when an older person complains
about his or her memory and does not show any
actual cognitive impairment or cognitive decline,
one should be aware that these symptoms might
reflect psycho-affective or health problems. Cuesta
et al. [1996] stated that there is a relationship between
cognitive complaints and neuropsychological disturbances in schizophrenic patients. However, other
studies found no relationship between subjective
cognitive symptoms and neuropsychological performance in chronic schizophrenics [Zanello and
Huguelet, 2001].
Although there have been some studies about the
association between cognitive complaints and neuropsychological disturbances in different psychiatric disorders, research about the relationship between
memory complaints and objective cognitive disturbances in MDD patients is scarce.
The aim of this study is to determine whether
subjective memory complaints represent objective
memory performance in patients with MDD and to
establish the demographic and clinical characteristics
of MDD patients with memory complaints.
METHOD
SUBJECTS
Participants were patients with MDD according to
DSM-IV (Diagnosis and Statistical Manual for Mental
Disorders-fourth edition) criteria and were enrolled in
the Major Depressive Disorder Program at Hafez
University Hospital in Shiraz, Iran. The length of the
enrollment period was 6 weeks, and more than 80% of
the patients were discharged at the end of the period.
Subjects with any disorder that could contribute to
neuropsychological impairments, such as medical
illness, history of head injury, neurodegenerative
disorder, substance dependence or abuse in the last
year, mental retardation or electroconvulsive therapy,
in the last year were excluded from the study. Also,
patients were taking no medications for any reason for
1 month prior up to and including the study date.
Seventy patients were initially included in the protocol,
Depression and Anxiety DOI 10.1002/da
but ultimately 64 patients gave written informed
consent to participate in the study after procedures
had been fully explained to them. Other exclusion
criteria included: (a) patients with other DSM-IV
diagnosis; (b) patients with psychotic symptoms; and
(c) patients unable to read, write or talk. Thirty healthy
controls without psychiatric or neurological history
were also recruited from a pool of normal volunteers
through advertisements. Only those subjects who did
not meet the criteria for any axis I psychiatric disorder,
as assessed by the Structured Clinical Interview for
Diagnostic Symptoms [DSM-IV; American Psychiatric
Association, 1994], were included as normal controls.
Also, controls had no first-degree relatives with
a mood disorder diagnosis. Ethical approval for the
study was granted by the Ethics Committee of Shiraz
University of Medical Sciences. There were no
significant differences between the control and patient
groups with respect to age, gender or educational
level.
ASSESSMENTS
MDD was diagnosed through the Structured Clinical
Interview for Diagnostic Symptoms (DSM-IV) by
a trained psychiatrist. The severity and clinical
characteristics of depression were assessed with
Hamilton Depression Scale-17 [Hamilton, 1960].
Overall functioning status was assessed with the
Global Assessment of Functioning (GAF, DSM-IV).
The original GAF instructions call for rating
symptoms or functioning. Because many other
measures of mood symptoms were obtained as part of
the evaluation, the evaluator was instructed to use the
GAF to measure psychosocial functioning in the month
before evaluation.
Subjective memory ability was evaluated by directly
questioning the patients. All subjects were asked about
their global evaluation of their memory (their ability to
recall current events, remember names or keep up with
their daily schedule). Scores for this question ranged
from 1 to 4, with scores 1, 2, 3 and 4 indicative of
severe, moderate, mild or no impairment, respectively.
Those patients who reported severe and moderate
subjective complaints (scores of 1 and 2) were included
in the group ‘‘with memory complaints’’, whereas those
who denied experiencing cognitive problems or had
mild complaints (scores of 3 and 4) were included in
the group ‘‘without memory complaints’’.
Objective memory was measured by the following
subtests of the Wechsler Memory Scale-III (WMS-III)
[Wechsler, 1997]: general information, orientation,
logical memory I and II, verbal paired associates
I and II, mental control, digit span forward and
backward and family pictures I and II. WMS-III has
been translated to Persian and has sufficient validity
and reliability to be used in Persian-speaking patients
[Ourangee et al., 2002].
Research Article: Do Memory Complaints Represent Impaired Memory
3
STATISTICAL ANALYSIS
w2 and independent sample t test were used to
compare demographic and clinical variables of the
groups, as appropriate. Depressive characteristics and
severity of MDD patients with memory complaints
were compared with those without memory complaints
with independent sample t test. The three groups
(MDD patients with memory complaints, without
memory complaints and healthy controls) were
compared for memory performance using one-way
analysis of variance, followed by Tukey post hoc
comparison procedure when significant main effects
were present.
However, patients with memory complaints performed
better than patients without memory complaints in
subtests of general information and logical memory.
Both MDD groups had poorer scores on the WMS
than the control group (Table 3).
RESULTS
TABLE 2. Depressive characteristics based on subtests
of HAMD in major depressive patients with and without
cognitive complaints
Forty-three percent of the patients with MDD
(n 5 28) reported moderate or severe subjective memory complaints. The mean age of the MDD
participants and their mean years of study were 32.3
and 9.5, respectively. The demographic and clinical
variables of MDD patients with and without memory
complaints and the control group are depicted in
Table 1. Patients with MDD with memory complaints
had lower educational level, longer duration and were
of a younger age at the time of presentation of their
illness than those without memory complaints. They
also showed lower scores on the GAF, which indicated
poorer psychosocial functioning.
The control group had significantly higher
educational level than MDD patients with memory
complaints but not than those without memory
complaints.
There was no important difference between the two
MDD groups with respect to severity of depression.
The two MDD groups also did not differ significantly
in most depressive characteristics, except for weight
loss and hypochondriac symptoms (Table 2).
MDD patients with and without memory complaints
showed no significant differences in WMS total score.
DISCUSSION
To our knowledge, this is the first study with respect
to the relationship between memory complaints and
objective memory performance in patients with MDD.
It also evaluates depressive characteristics and
HAMD total score
Depressive mood
Feeling of guilt
Suicidality
Insomnia early
Insomnia middle
Insomnia late
Work and activity
Retardation
Agitation
Psychological anxiety
Somatic anxiety
Gastrointestinal symptoms
General somatic symptoms
Genital symptoms
Hypochondriasis
Loss of weight
Insight
With
memory
complaint
mean (SD)
Without
memory
complaint
mean (SD)
32.6
3.3
1.9
2.0
.71
.82
.78
2.3
.57
.89
2.5
2.1
.89
.96
1.0
1.3
.67
.17
26.0
3.0
1.6
2.3
1.1
1.0
.94
2.3
.77
.91
2.3
2.3
.66
1.2
1.2
.53
.30
.25
(21.0)
(.8)
(.9)
(1.0)
(.9)
(.9)
(.9)
(1.0)
(.7)
(.56)
(.8)
(1.1)
(.7)
(.79)
(.7)
(1.1)
(.9)
(.47)
Statistics
P value
(7.36)
(.9)
(.8)
(.6)
(.9)
(.9)
(.9)
(1.0)
(.7)
(.6)
(1.0)
(1.0)
(.6)
(.8)
(.6)
(1.0)
(.6)
(.5)
.95
.19
.15
.32
1.0
.39
.48
.95
.28
.90
.33
.52
.25
.11
.34
.003
.002
.58
HAMD, Hamilton Depression Scale.
TABLE 1. Demographic and clinical variables of major depressive disorder patients with and without memory
complaints and control group
Statistic
MDD and A and
B mean (SD)
Age (years)
Sex (female %)
Education (years)
Unemployment (%)
Married (%)
Age at onset
Chronicity (years)
GAF
32.3
76.0
9.5
25.5
68.9
24.1
13.9
67.4
(9.6)
(4.1)
(8.1)
(8.7)
(13.1)
MDD and A
mean (SD)
30.5
71.4
11.0
28.8
60.1
21.9
16.2
62.6
(9.5)
(3.6)
(7.0)
(8.9)
(13.4)
MDD and B
Mean (SD)
34.3
80.6
7.9
22.2
77.8
26.3
11.6
72.3
(9.5)
(4.0)
(8.7)
(8.5)
(12.8)
C mean (SD)
A/B
A/C
B/C
33.2 (8.9)
80
8.0 (4.1)
10
83.3
.80
.39
.004
.56
.14
0.032
0.044
0.009
.18
.45
.01
.07
.05
.64
.95
.94
.18
.57
A, with memory complaint; B, without memory complaint; C, control group. GAF, Global Assessment of Functioning; MDD, major depressive
disorder.
Depression and Anxiety DOI 10.1002/da
4
Mowla et al.
TABLE 3. Memory performance in major depressive patients with and without cognitive complaints and control group
ANOVA
MDD and A
mean (SD)
WMS total score
General information
Time and place orientation
Mental control
Logical memory I
Digit span
Verbal paired associates I
Logical memory II
Family picture I
Verbal paired associates II
Family picture II
77.9
5.6
4.5
7.2
9.3
8.6
15.6
7.8
6.1
5.9
7.9
(20.7)
(.6)
(.6)
(.6)
(3.9)
(2.2)
(3.2)
(3.4)
(4.1)
(1.1)
(3.9)
MDD and B
mean (SD)
72.5 (18.3)
5.0 (1.1)
4.3 (.72)
7.3 (1.4)
7.4 (3.5)
7.9 (1.6)
14.6 (3.5)
7.08 (2.9)
6.36 (3.7)
5.5 (1.47)
6.5 (2.9)
C mean (SD)
88.9
5.0
4.5
7.0
9.0
8.5
16.7
7.6
7.9
6.0
7.2
(21.1)
(1.1)
(.73)
(2.0)
(4.2)
(2.1)
(3.3)
(3.4)
(4.4)
(1.17)
(3.49)
Tukey post hoc test
F
P
A/B
A/C
B/C
5.5
3.4
.47
.30
2.3
1.2
2.8
.53
1.2
1.7
1.4
.005
.037
.621
.738
1.00
.282
.060
.581
.289
.177
.249
.176
.021
.441
.823
.046
.207
.338
.276
.476
.318
.091
.04
.019
.812
.880
.775
.764
.168
.713
.564
.574
.360
.002
.902
.333
.757
.136
.243
.027
.517
.178
.106
.550
WMS, Wechsler Memory Scale; A, with memory complaint; B, without memory complaint; C, control group.
demographic variables of depressed patients with and
without memory complaints. Our study showed that
memory complaints were seen in about half of all
MDD patients. The MDD patients with subjective
complaints had lower educational level, longer
duration of illness and earlier age of presentation
compared with those without subjective complaints.
They also received lower scores on the GAF, which
demonstrates poorer psychosocial functioning. Contrary to our study, Peralta and Cuesta [1998] found no
association between clinical factors and cognitive
complaints in their affective disorders sample. In a
survey studying the cognitive complaints in euthymic
bipolar patients, it was concluded that bipolar patients
who were aware of cognitive deficits were more
chronic, had more previous episodes, especially mixed
type, and their illness had started at an earlier age, and
they were associated with more social and occupational
functional deficit [Martınez-Aran et al., 2005]. In our
study, there were no significant differences between the
MDD groups with respect to gender, age, marital and
employment status.
Our results demonstrated that MDD patients with
memory complaints were no different from those
MDD patients without memory complaints with
respect to severity and characteristics of depression,
except for hypochondria concerns. This is consistent
with some earlier studies, which suggested that
psychiatric patients who complained about their
memory had more tendencies toward somatic
complaining, higher feelings of anxiety about their
physical health, and more negative feelings about their
own competence and capabilities than those who did
not complain of memory deterioration [Hanninen
et al., 1994].
Major depressed patients with memory complaints
had no significant differences than those without
memory complaints regarding objective memory
performance. Moreover, patients who did not report
Depression and Anxiety DOI 10.1002/da
memory defects obtained even lower scores in some
subtests of the WMS, such as logical memory I and
general information. In a study performed on different
psychiatric patients, it was demonstrated that perceived
subjective memory is not related to actual memory
deficits in psychiatric patients [Moritz et al., 2004].
Martınez-Aran et al. [2005] found that cognitive
complaints in euthymic bipolar patients are not a good
indicator of objective cognitive impairment. In
demented elderly patients, almost all studies did not
demonstrate positive correlation between memory
complaints and objective memory performance
[Pearman and Storandt, 2005; Zandi, 2004; Zelinski
et al., 2001]. In a cross-sectional investigation in the
context of a community-based cohort study, no
difference was found between complainers and noncomplainers with regard to actual memory
performance [Jungwirth et al., 2004]. Positive association between cognitive complaints and neuropsychological disturbances has been found in schizophrenic
patients [Cuesta et al., 1996]. However, further studies
found no relationship between subjective cognitive
symptoms and neuropsychological performance in
chronic schizophrenic patients [Zanello and Huguelet,
2001].
A healthy control group was also included in
our study to determine true neuropsychological
impairments. Patients with MDD with and without
memory complaints had lower scores in WMS than
control group. Therefore, even those without memory
complaints should be objectively evaluated, at least
through a brief neuropsychological assessment, because
some patients who do not complain may also show true
memory impairment. One of the limitations of this
study was the sample size. A larger sample would
display significant differences more clearly. Another
shortcoming of this study is that we focused on the core
symptoms of major depression that are assessed by the
Hamilton Depression Scale for Depression. It is
Research Article: Do Memory Complaints Represent Impaired Memory
possible that other domains, such as executive
functioning, that have been shown to be impaired in
MDD patients [Grant et al., 2001; Ottowitz et al.,
2002] may demonstrate different effects in our groups.
Studying aspects of neuropsychology other than
memory may give a better understanding of cognition
in the patients.
CONCLUSION
Our study demonstrated that memory complaints do
not represent objective memory impairment in MDD
patients. Therefore, subjective memory complaints are
not valid indictors of objective memory impairments.
In this study, we observed no association between
severity of depression and more memory complaints
in depressed patients. However, those patients with
more hypochondria concerns had more memory
complaints. In addition, patients with more memory
complaints had more functional disabilities, longer
duration and younger age of presentation of their
illness than those without memory complaints.
REFERENCES
American Psychiatric Association. 1994. Diagnostic & statistical
manual of mental disorder: Revised (4th ed.). Washington, DC:
American Psychiatric Association.
Beck AT, Rush AJ, Shaw BF. 1979. Cognitive therapy of depression.
New York, NY: Guilford.
Chamelian L, Feinstein A. 2006. The effect of major depression on
subjective and objective cognitive deficits in mild to moderate
traumatic brain injury. J Neuropsychiatry Clin Neurosci 18:33–38.
Comijs HC, Deeg DJ, Dik MG, Twisk JW, Jonker C. 2002. Memory
complaints; the association with psycho-affective and health
problems and the role of personality characteristics. A 6-year
follow-up study. J Affect Disord 72:157–165.
Cuesta MJ, Peralta V, de Leon J. 1996. Neurological frontal signs and
neuropsychological deficits in schizophrenic patients. Schizophr
Res 20:15–20.
Derouesne C, Lacomblez L, Thibault S, LePoncin M. 1999. Memory
complaints in young and elderly subjects. Int J Geriatr Psychiatry
14:291–301.
Grant MM, Thase ME, Sweeney JA. 2001. Cognitive disturbances
in outpatient depressed younger adult: Evidence of modest
impairment. Biol Psychiatry 50:35–43.
Hamilton M. 1960. A rating scale for depression. J Neurol
Neurosurg Psychiatry 23:56–62.
Hanninen T, Reinikainen KJ, Helkala EL, Koivisto K, Mykkanen L,
Laakso M, Pyorala K, Riekkinen PJ. 1994. Subjective memory
5
complaints and personality traits in normal elderly subjects.
J Am Geriatr Soc 42:1–4.
Jungwirth S, Fischer P, Weissgram S, Kirchmeyr W, Bauer P, Tragl
KH. 2004. Subjective memory complaints and objective memory
impairment in the Vienna-Transdanube aging community.
J Am Geriatr Soc 52:263–268.
Martınez-Aran A, Vieta E, Colom F, Torrent C, Reinares M,
Goikolea JM, Benabarre A, Comes M, Sanches-Moreno J. 2005.
Do cognitive complaints in euthymic bipolar patients reflect
objective cognitive impairment? Psychother Psychosom
74:295–302.
Moritz S, Ferahli S, Naber D. 2004. Memory and attention
performance in psychiatric patients: Lack of correspondence
between clinician-rated and patient-rated functioning with
neuropsychological test results. J Int Neuropsychol Soc 10:
623–633.
Ottowitz WE, Dougherty DD, Savage CR. 2002. The neural
network basis for abnormalities of attention and executive function
in major depressive disorder: Implication for application of the
medical disease model to psychiatric disorders. Harv Rev
Psychiatry 10:86–99.
Ourangee M, Atef-Vahid MK, Ashayeri H. 2002. Normalization of
Wechsler Memory Scale-Revised in Shiraz. Andisheh Va Raftar
4:56–66.
Pearman A, Storandt M. 2005. Self-discipline and self-consciousness
predict subjective memory in older adults. J Gerontol B Psychol
Sci Soc Sci 60:153–158.
Peralta V, Cuesta MJ. 1998. Subjective experiences in psychotic
disorders: Diagnostic value and clinical correlates. Compr
Psychiatry 39:11–15.
Reid LM, Maclullich AM. 2006. Subjective memory complaints and
cognitive impairment in older people. Dement Geriatr Cogn
Disord 22:471–485.
Rohling ML, Green P, Allen LM, Iverson GL. 2002.
Depressive symptoms and neurocognitive test scores in patients
passing symptom validity tests. Arch Clin Neuropsychol 17:
205–222.
Tsushima WT, Johnson DB, Lee JD, Matsukawa JM, Fast KMS.
2005. Depression, anxiety and neuropsychological test scores of
candidates for coronary artery bypass graft surgery. Arch Clin
Neuropsychol 20:667–673.
Wechsler D. 1997. The Wechsler Memory Scale. San Antonio, Tex:
Psychological Corp (Harcourt).
Zandi T. 2004. Relationship between subjective memory complaints,
objective memory performance, and depression among older
adults. Am J Alzheimers Dis Other Demen 19:353–360.
Zanello A, Huguelet P. 2001. Relationship between subjective
cognitive symptoms and frontal executive abilities in chronic
schizophrenic outpatients. Psychopathology 34:153–158.
Zelinski EM, Burnight KP, Lane CJ. 2001. The relationship between
subjective and objective memory in the oldest old: Comparisons of
findings from a representative and a convenience sample. J Aging
Health 13:248–266.
Depression and Anxiety DOI 10.1002/da