Visuoconstructional Drawing Ability in the Differential Diagnosis of Neurologic Compromise Versus Depression

Archives of Clinical Neuropsychology, Vol. 14, No. 4, pp. 359–372, 1999 Copyright © 1999 National Academy of Neuropsychology Printed in the USA. All rights reserved 0887-6177/99 $–see front matter PII S0887-6177(98)00026-2 Visuoconstructional Drawing Ability in the Differential Diagnosis of Neurologic Compromise Versus Depression Leslie D. Rosenstein Department of Psychiatry, Scott and White Clinic and Memorial Hospital; Scott, Sherwood and Brindley Foundation; and Texas A&M University Health Science Center, College of Medicine Neuropsychologists are often called upon to assist in making differential diagnoses between neurologic compromise and depression. However, the literature has been inconsistent about the impact of depression on neurocognitive functioning. This makes interpretation of neuropsychological test data among depressed individuals difficult. In a retrospective cross-sectional study of 200 patients, the relationship between depression (Beck Depression Inventory or Geriatric Depression Scale) and visuoconstructional drawing ability/praxis (Rey-Osterrieth Copy [RO]) was evaluated. Age and education both correlated significantly with RO performance (p , .001 and .005, respectively). There were no significant relationships found between copy performance and depression, even when controlling for the significant effects of age and education. A prospective longitudinal study of 20 psychiatric inpatients with depression tested on admission and again at discharge matched with 20 nondepressed normal controls yielded similar results in that the two groups did not differ in their initial RO performance. Moreover, an improvement in depression as measured by a decrease in Beck Depression Inventory scores did not coincide with any improvement in RO scores. By comparison, a matched positive control group of 20 neurologically compromised patients was significantly worse than both the normal control and the depressed groups on the RO (p , .05). These data suggest that poor performance on the RO should not be interpreted simply as a consequence of depression. Age and education, though, should be considered when interpreting the RO. © 1999 National Academy of Neuropsychology. Published by Elsevier Science Ltd Neuropsychologists are often called upon to assist in making differential diagnoses between neurologic compromise and depression. Visuoconstructional drawing ability is often included in these evaluations. However, there have been few studies of the impact of depression on visuoconstructional drawing ability. Moreover, studies of neurocognitive functioning in depression, in general, have yielded inconsistent findings. The author wishes to acknowledge Ms. Carolyn Kamenicky for her diligence in recruiting participants for the prospective study and Ms. Robin Sykes for her assistance in coding data for the retrospective study. Ms. Nicoletta Karantzoulis, MA and Ms. Heather Heath are also thanked for their assistance with blinding and other clerical activities. Finally, Dr. Keith A. Young is thanked for his helpful comments. Address correspondence to Leslie D. Rosenstein, PhD, Department of Psychiatry, Scott and White Clinic and Memorial Hospital, 2401 South 31st Street, Temple, TX 76508. 359 360 L. D. Rosenstein This latter observation can be attributed, in part, to methodological difficulties associated with finding, accessing, recruiting, and testing psychiatric patients who are otherwise free of neurologic compromise. There have been some well-controlled studies, most of which have not found strong and consistent relationships between neurocognitive measures and depression (see Poon, 1992; Rosenstein, 1999, for reviews). Grossman, Kaufman, Mednitsky, Scharff, and Dennis (1994) suggested that earlier reports of cognitive difficulties among depressed individuals stemmed from methodological flaws, such as poorly developed assessment tools and poorly matched control groups. Those investigators did not find differences between their depressed sample versus matched controls in terms of intelligence quotient (IQ). Regarding visuospatial functions, specifically, Lyness, Eaton, and Schneider (1994) did not find impairments among currently unmedicated depressed individuals. Visuospatial measures administered included puzzle assembly, facial recognition, and immediate and delayed visuospatial memory/reproduction. The depressed individuals were worse compared to age-matched controls on measures of psychomotor speed. They were not worse on additional measures, including those assessing verbal memory, span of attention, and verbal fluency. In contrast to the above study, Sackeim et al. (1992) found differences in Performance IQ, but not Verbal IQ, among inpatients during a major depressive episode, versus well-matched controls. Interestingly, the less severely depressed patients had the greatest Verbal-Performance IQ discrepancies. In addition to lower Performance IQs, the depressed patients had lower Digit Span scores. With extended test times, Performance IQs improved, but remained significantly lower than Verbal IQs. Performance IQs also improved significantly among a subsample of depressed patients 1 week after treatment with electroconvulsive therapy (ECT), as well as among a subsample tested 2 months following ECT. Again, though, there remained a Verbal-Performance discrepancy. While well-controlled in terms of most matching variables and medication washout, the groups in the Sackeim et al. (1992) study differed from one another in that 17 of the 100 depressed patients were left-handed, as compared with 0 of the 50 controls. Moreover, 25 of the patients were actually diagnosed with bipolar disorder and 36 were experiencing current psychosis. However, the authors compared patient subgroups on the basis of hand preference, unipolar versus bipolar depression, retarded (n 5 54) versus nonretarded depression, and history of prior ECT (n 5 42) versus no such history, and found no significant differences. There was no mention of whether the nonpsychotic, right-handed, unipolar depressed patients without history of ECT were compared directly to the controls. In a study of the effect of ECT on cognitive functioning, Rossi et al. (1990) reported data concerning the relationship between Rey-Osterrieth Copy (RO) performance and depression. The RO (Rey, 1941 and Osterrieth, 1944, as cited in Spreen & Strauss, 1991) is a test frequently used to measure visuoconstructional drawing ability in evaluations of patients in which there is a question of neurologic compromise. In fact, the RO has been shown to be sensitive to a variety of impairments associated with pathological conditions of the brain (see Lezak, 1995 and Spreen & Strauss, 1991 for reviews). Rossi et al. (1990) found that depressed patients with major affective disorders performed worse than healthy age-, sex-, and education-matched controls on the RO. Among the depressed patients, though, there was no relationship betwee (...truncated)