Patients with depression spends 94% of their time with cognitive symptoms-Farid Aslam Minhas

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 THINC Symposium on Cognitive Dysfunction in Depression-II

Patients with depression spends 94% of their time
with cognitive symptoms - Farid Aslam Minhas

Cognitive remission is now possible with drug therapy-Dr. Shehla Alvi

KARACHI: Lundbeck Pakistan organized the second workshop in the series of THINC Expert Forumas a part of the 100 Years Celebrations at Karachi on November 7th 2016. Prof. S. Haroon Ahmad an eminent psychiatrist was the chief guest on this occasion and the meeting attracted psychiatrists from Quetta, interior of Sindh and Karachi. Dr. Shehla Alvi from United Medical & Dental College was the moderator of the first session. In her introductory remarks she said that by 2030 Depression is going to be the leading cause of disability worldwide. Psychiatric patients impact life of others and neighborhood.  Conative dysfunction is one of the symptoms of depression.  Cognitive impairment is common in depression and it leads to poor academic, occupational outcome.  Life functions are also impaired due to depression.

Management of these patients can be categorized in to response to therapy, remission and functional remission.  First symptomsreduction takes place which is followed by remission and then final remission means cognitive remission. She was of the view that in 2014 now cognitiveremission is possible with drug therapy.


Group photograph shows participants of THINC Symposium on Cognitive Dysfunction in Depression organized
by Lundbeck at Karachi recently along with facilitators and senior executives of Lundbeck.

This was followed by an excellent presentation on role of cognitive dysfunction in depression by Prof. Farid Aslam Minhas from Institute of Psychiatry, Rawalpindi. Depression, he said, leads to decreased ability to think or concentrate, the patient is indecisive, psychomotor retardation takes place, patient is agitated, their concentration is reduced, they have no short term memory, they suffer from lack of focus, their brain is cloudy, they lack confidence and when you are talking to them, they may not be listening at all. Depressed patients are tired, lethargic, have slow motion, forgetful and are confused. You should know how to treat these patients, once they are diagnosed, Prof. Farid Aslam Minhas remarked.


He then talked about British Columbia Cognitive Complaints Inventory and referred to some local studies. A study conducted at Benazir Bhutto Hospital Rawalpindi which included 292 elderly depressed patients showed that 70% of them were suffering from cognitive dysfunction.  It included thirty three who suffered from mild, thirty two from moderate and six patients from severe impairment.  He also talked about symptomatology of Alzheimer’s disease and mental state examination. In yet another study by Prof. Iqbal Afridi et al from JPMC looked at the cognitive disturbances in depressed patients. Sixty patients were included in this study between the age of 18-40 years and it showed that 63.3% of them had cognitive difficulties compared to healthy controls. Speaking about psycho educaiton it was stated that treatment is more difficult in patients who are inattentive and have impaired memory. Medication adherence is yet another problem in these patients while psychotherapy was in part learning dependent. In Pakistan we have just about three to four hundred psychiatrists hence one to one psychotherapy is not possible and it is going to fail. We at Rawalpindi, Prof. Farid Aslam Minhas remarked have been training primary healthcare physicians, mental health workers, school teachers to deliver psychological interventions and they have been doing this as good as trained mental healthcare professionals. We are implementing brief version of psychotherapy in this training.Psychotherapy, Prof. Farid Aslam Minhas remarked will also interfere with treatment in cognitive dysfunction patients. No single scale is good enough for assessing cognitive dysfunction. Psychiatrists have to wake up and find out how to assess these patients with cognitive dysfunction since most of the scales are not validated in local population, Prof. Farid Aslam Minhas concluded.

Prof. Razaur Rahman from Dow University of Health Sciences talked about Hot a d Cold Cognitive Dysfunction theory. He admitted that when he first heard about it, it was a new concept for him as well. Explaining the Hot concept, he said that it is when you are in stress, you are likely to make wrong decisions. However, the Cold concept is when you are not under any stress and you won’tmake any mistakes. Abnormalities exist in hot cognition. These are difficult concepts and we need to understand them. Cold cognition is not influenced by emotions but hot cognition is influenced by depression.


Dr. Majid Abidi was the moderator for the second session. The participants were divided into different groups and they discussed, debated how to recognize the depressed patients with cognitive dysfunction in the light of the video clip of a depressed patients which was shown to them. Later the group representatives made the pretentions. Dr. Zain speaking on behalf of one of the groups said that forgetfulness, attention deficit,  academic problems,  problems in planning, fear of being a poor mother, negative thinking, fatigue, avoidance, hopelessness and impaired memory were  some of the symptoms which they could pick up on the narration of this patient. Hold and Cold concept, he said, was new to many in the group. After this session, they will be able to improve the management of depression.

Dr. Ajmal Kazmi giving feedback from another group said that besides the symptoms recognized by the first group, they could also find out that the patient was complaining of low self-esteem, forgetfulness and negative thinking. We see these symptoms in our patients daily. The patinet also complained that she could not be a good mother and good wife. However, the Hot and Cold concepts, he stated, was not yet clear to them.


Col. Ramzan presented the viewpoint of another group and opined that these terminologies of Hot and Cold needs to be made further clear. The deliberations and discussions in today’s symposium, will definitely help in improving their psychiatric practice.Dr. Capitan Jamil Ahmad remarked that the number of psychiatrists was over four hundred thirty in the country and one hundred sixteen were in Sindh province. Dr.  Amanat Mohsin remarked that he has noticed that some of these anti-depressants have cognitive side effects as well.  At this it was stated that Lithium was one of the drugs which does affect cognition.

Prof. Syed Haroon Ahmad in his address said that psychiatrists and Pharma industry should work together to promote psychiatry and academics. Unfortunately there are lot of complaints regarding physician’s interaction with the Pharma industry wherein some doctors are working for the Pharma industry to promote their drugs and sale. We need to abide by professional ethics and promote psychiatry and psychiatric practice. Once this happens, drugs sales will improve automatically. He was glad to notice that in today’s academic activity no drug was being discussed at all. Our emphasis, Prof. Haroon Ahmad remarked should be on education and professional capacity building of healthcare professionals.


Many years ago when they organized the first Psychiatric conference the only psychiatric  diseases which used to be discussed most often were anxiety, depression and drugs available included anti-anxiety drugs, anti-depressants and antipsychoticmedications. Since then there has been tremendous improvement. He once again reiterated that there was no harm in collaboration with the Pharma industry if it is meant for promotion of psychiatry, psychiatric practice and emphasis remains on academics and education.


Photographed during the THINC Symposium on Cognitive Dysfunction in
Depression organized by Lundbeck at Karachi recently from (R to L) are
Mr.  Khalid Zia, Mr. Imran Majid,  Dr. Ajmal Kazmi, Prof Abdul Malik,
Mr. Aslam Sheikh from Lundbeck, Mr. Shaukat Ali Jawaid and Dr. Inam Rasool. 

Mr. Shaukat Ali Jawaid speaking at the occasion commended the initiative taken by Prof. S. Haroon Ahmad in 1970 to form the Pakistan Psychiatric Society when they had just few members and they had to involve family physicians to hold their first meeting.  Over the years psychiatry has made tremendous progress and now Pakistan Psychiatric Society has emerged as a very important effective body of mental healthcare professionals. He also recalled that once a senior psychiatrist who had developed nerve deafness came to see him in late 70s. He said that ever since his hearing is impaired his practice has improved a lot. When he was asked to share the secret of this success, the senior psychiatrist remarked that he had employed two young competent doctors who first see the patients, prepare the case sheet with symptoms after carefully listening to the patient and then the patient comes to me. I give them enough time to tell their story and though I do not hear most often what the patient is saying, I study the case sheet and the symptoms prepared by the young doctors. Once the patient has narrated their story, then I talk to them and write the prescription. The patients thank him and leave is chamber highly satisfied thanking me that I heard them patiently.  The take home message in the story, Mr. Shaukat Ali Jawaidsaid was that the doctors must listen to the patient patiently and attentively. He is happy to note that both those young doctors have now become eminent psychiatrists in their own right. Doctors, he said, need to be trained not only in communication skills but listening skills as well. In many cases, the patient has not told his story and complaints yet but the long list of investigations and a prescription is ready. This does not satisfy the patient and patient satisfaction was extremely important. There can be no substitute to clinical skills, good history taking and physical examination to come to correct diagnosis he added.


In the second session Dr. Ayesha Quraishy spoke about how to recognize depressed patient with cognitive dysfunction. She talked about the patient self-reporting scales, neurocognitive test and cognitive domains known to be effected in MDD. She was of the view that we need tests whichare reliable, valid, sensitive,and immune to practice effectsand are sustainable for long term use. She then referred to Digital Symptoms Substitution Test (DSST) and also referred to the THINC ITCognition Tool. We should pick test based on their quality and psychiatrist’s involvement has to be a therapeutic intervention, she added.

In the afternoon session management of cognitive symptoms in patients with MDD and patients with cognitive dysfunction with depression was discussed in the two workshops. It was followed with a concluding session wherein summary of the daylong deliberations were shared with the participants.

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