Skip to main content Accessibility help

Cognitive impairment in depression: a systematic review and meta-analysis

  • P. L. Rock (a1) (a2), J. P. Roiser (a3), W. J. Riedel (a1) (a4) (a5) and A. D. Blackwell (a1) (a4)



This review aimed to address the question of whether cognitive impairment should be considered a core feature of depression that may be a valuable target for treatment.


We conducted a systematic review and meta-analysis of cognitive function, assessed with a single neuropsychological test battery, the Cambridge Neuropsychological Test Automated Battery (CANTAB), in patients with depression during symptomatic and remitted states. Inclusion of studies comparing patients remitted from depression and controls enabled us to investigate whether cognitive impairment persists beyond episodes of low mood in depression.


Our meta-analysis revealed significant moderate cognitive deficits in executive function, memory and attention in patients with depression relative to controls (Cohen's d effect sizes ranging from −0.34 to −0.65). Significant moderate deficits in executive function and attention (Cohen's d ranging from −0.52 to −0.61) and non-significant small/moderate deficits in memory (Cohen's d ranging from −0.22 to −0.54) were found to persist in patients whose depressive symptoms had remitted, indicating that cognitive impairment occurs separately from episodes of low mood in depression.


Both low mood and cognitive impairment are associated with poor psychosocial functioning. Therefore, we argue that remediation of cognitive impairment and alleviation of depressive symptoms each play an important role in improving outcome for patients with depression. In conclusion, this systematic review and meta-analysis demonstrates that cognitive impairment represents a core feature of depression that cannot be considered an epiphenomenon that is entirely secondary to symptoms of low mood and that may be a valuable target for future interventions.


Corresponding author

* Address for correspondence: P. L. Rock, D.Phil., Cambridge Cognition, Tunbridge Court, Tunbridge Lane, Bottisham, Cambridge CB25 9TU, UK. (Email:


Hide All
Abas, M, Sahakian, BJ, Levy, R (1990). Neuropsychological deficits and CT scan changes in elderly depressives. Psychological Medicine 20, 507520.
Afridi, M, Hina, M, Qureshi, I, Hussein, M (2011). Cognitive disturbance comparison among drug-naïve depressed cases and healthy controls. Journal of the College of Physicians and Surgeons – Pakistan 21, 351355.
Angold, A, Costello, EJ (1995). A test-retest reliability study of child-reported psychiatric symptoms and diagnoses using the Child and Adolescent Psychiatric Assessment (CAPA-C). Psychological Medicine 25, 755762.
Angold, A, Erkanli, A, Silberg, J, Eaves, L, Costello, EJ (2002). Depression scale scores in 8–17-year-olds: effects of age and gender. Journal of Child Psychology and Psychiatry, and Allied Disciplines 43, 10521063.
APA (2000). Diagnostic and Statistical Manual of Mental Disorders – Text Revision. American Psychiatric Association: Washington, DC.
Beats, BC, Sahakian, BJ, Levy, R (1996). Cognitive performance in tests sensitive to frontal lobe dysfunction in the elderly depressed. Psychological Medicine 26, 591603.
Beck, A (1961). A systematic investigation of depression. Comprehensive Psychiatry 2, 163170.
Bhalla, RK, Butters, MA, Mulsant, BH, Begley, AE, Zmuda, MD, Schoderbek, B, Pollock, BG, Reynolds, CF 3rd, Becker, JT (2006). Persistence of neuropsychologic deficits in the remitted state of late-life depression. American Journal of Geriatric Psychiatry 14, 419427.
Boeker, H, Schulze, J, Richter, A, Nikisch, G, Schuepbach, D, Grimm, S (2012). Sustained cognitive impairments after clinical recovery of severe depression. Journal of Nervous and Mental Disease 200, 773776.
Bora, E, Harrison, BJ, Yücel, M, Pantelis, C (2013). Cognitive impairment in euthymic major depressive disorder: a meta-analysis. Psychological Medicine 43, 20172026.
Braw, Y, Aviram, S, Bloch, Y, Levkovitz, Y (2011). The effect of age on frontal lobe related cognitive functions of unmedicated depressed patients. Journal of Affective Disorders 129, 342347.
Burt, DB, Zembar, MJ, Niederehe, G (1995). Depression and memory impairment: a meta-analysis of the association, its pattern, and specificity. Psychological Bulletin 117, 285305.
Butters, MA, Whyte, EM, Nebes, RD, Begley, AE, Dew, MA, Mulsant, BH, Zmuda, MD, Bhalla, R, Meltzer, CC, Pollock, BG, Reynolds, CF 3rd, Becker, JT (2004). The nature and determinants of neuropsychological functioning in late-life depression. Archives of General Psychiatry 61, 587595.
Cannon, DM, Klaver, JM, Peck, SA, Rallis-Voak, D, Erickson, K, Drevets, WC (2009). Dopamine type-1 receptor binding in major depressive disorder assessed using positron emission tomography and [11C]NNC-112. Neuropsychopharmacology 34, 12771287.
Clark, L, Kempton, MJ, Scarnà, A, Grasby, PM, Goodwin, GM (2005 a). Sustained attention-deficit confirmed in euthymic bipolar disorder but not in first-degree relatives of bipolar patients or euthymic unipolar depression. Biological Psychiatry 57, 183187.
Clark, L, Sarna, A, Goodwin, GM (2005 b). Impairment of executive function but not memory in first-degree relatives of patients with bipolar I disorder and in euthymic patients with unipolar depression. Journal of Medical Genetics 162, 19801982.
Cohen, J (1988). Statistical Power Analysis for the Behavioral Sciences, 2nd edn. Lawrence Erlbaum Associates: Mahwah, NJ.
DeBattista, C, Lembke, A, Solvason, HB, Ghebremichael, R, Poirier, J (2004). A prospective trial of modafinil as an adjunctive treatment of major depression. Journal of Clinical Psychopharmacology 24, 8790.
Douglas, KM, Porter, RJ (2009). Longitudinal assessment of neuropsychological function in major depression. Australian and New Zealand Journal of Psychiatry 43, 1105–1017.
Elliott, R, Baker, SC, Rogers, RD, O'Leary, DA, Paykel, ES, Frith, CD, Dolan, RJ, Sahakian, BJ (1997). Prefrontal dysfunction in depressed patients performing a complex planning task: a study using positron emission tomography. Psychological Medicine 27, 931942.
Elliott, R, Sahakian, BJ, McKay, AP, Herrod, JJ, Robbins, TW, Paykel, ES (1996). Neuropsychological impairments in unipolar depression: the influence of perceived failure on subsequent performance. Psychological Medicine 26, 975989.
Erickson, K, Drevets, WC, Clark, L, Cannon, DM, Bain, EE, Zarate, CA Jr., Charney, DS, Sahakian, BJ (2005). Mood-congruent bias in affective go/no-go performance of unmedicated patients with major depressive disorder. American Journal of Psychiatry 162, 21712173.
Grant, MM, Thase, ME, Sweeney, JA (2001). Cognitive disturbance in outpatient depressed younger adults: evidence of modest impairment. Biological Psychiatry 50, 3543.
Hamilton, M (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry 23, 5662.
Hasselbalch, BJ, Knorr, U, Kessing, LV (2011). Cognitive impairment in the remitted state of unipolar depressive disorder: a systematic review. Journal of Affective Disorders 134, 2031.
Heinzel, A, Northoff, G, Boeker, H, Boesiger, P, Grimm, S (2010). Emotional processing and executive functions in major depressive disorder: dorsal prefrontal activity correlates with performance in the intra-extra dimensional set shift. Acta Neuropsychiatrica 22, 269279.
Herrera-Guzmán, I, Gudayol-Ferré, E, Herrera-Abarca, JE, Herrera-Guzmán, D, Montelongo-Pedraza, P, Padrós Blázquez, F, Peró-Cebollero, M, Guàrdia-Olmos, J (2010). Major depressive disorder in recovery and neuropsychological functioning: effects of selective serotonin reuptake inhibitor and dual inhibitor depression treatments on residual cognitive deficits in patients with major depressive disorder in recovery. Journal of Affective Disorders 123, 341350.
Jaeger, J, Berns, S, Uzelac, S, Davis-Conway, S (2006). Neurocognitive deficits and disability in major depressive disorder. Psychiatry Research 145, 3948.
Judd, LL, Paulus, MP, Wells, KB, Rapaport, MH (1996). Socioeconomic burden of subsyndromal depressive symptoms and major depression in a sample of the general population. American Journal of Psychiatry 153, 14111417.
Kaufman, J, Birmaher, B, Brent, D, Rao, U, Flynn, C, Moreci, P, Williamson, D, Ryan, N (1997). Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry 36, 980988.
Kempton, S, Vance, A, Maruff, P, Luk, E, Costin, J, Pantelis, C (1999). Executive function and attention deficit hyperactivity disorder: stimulant medication and better executive function performance in children. Psychological Medicine 29, 527538.
Kyte, A, Goodyer, IM, Sahakian, BJ (2005). Selected executive skills in adolescents with recent first episode major depression. Journal of Child Psychology and Psychiatry 9, 9951005.
Lee, RSC, Hermens, DF, Porter, MA, Redoblado-Hodge, MA (2012). A meta-analysis of cognitive deficits in first-episode major depressive disorder. Journal of Affective Disorders 140, 113124.
Lyche, P, Jonassen, R, Stiles, TC, Ulleberg, P, Landrø, NI (2010). Cognitive control functions in unipolar major depression with and without co-morbid anxiety disorder. Frontiers in Psychiatry 1, 149.
Maalouf, FT, Brent, D, Clark, L, Tavitian, L, McHugh, RM, Sahakian, BJ, Phillips, ML (2011). Neurocognitive impairment in adolescent major depressive disorder: state vs. trait illness markers. Journal of Affective Disorders 133, 625632.
Maalouf, FT, Klein, C, Clark, L, Sahakian, BJ, Labarbara, EJ, Versace, A, Hassel, S, Almeida, JRC, Phillips, ML (2010). Impaired sustained attention and executive dysfunction: bipolar disorder versus depression-specific markers of affective disorders. Neuropsychologia 48, 18621868.
Matthews, K, Coghill, D, Rhodes, S (2008). Neuropsychological functioning in depressed adolescent girls. Journal of Affective Disorders 111, 113118.
McCall, W, Dunn, A (2003). Cognitive deficits are associated with functional impairment in severely depressed patients. Psychiatry Research 121, 179184.
McDermott, LM, Ebmeier, KP (2009). A meta-analysis of depression severity and cognitive function. Journal of Affective Disorders 119, 18.
Michopoulos, I, Zervas, IM, Pantelis, C, Tsaltas, E, Papakosta, V-M, Boufidou, F, Nikolaou, C, Papageorgiou, C, Soldatos, CR, Lykouras, L (2008). Neuropsychological and hypothalamic-pituitary-axis function in female patients with melancholic and non-melancholic depression. European Archives of Psychiatry and Clinical Neuroscience 258, 217225.
Michopoulos, I, Zervas, IM, Papakosta, VM, Tsaltas, E, Papageorgiou, C, Manessi, T, Papakostas, YG, Lykouras, L, Soldatos, CR (2006). Set shifting deficits in melancholic vs. non-melancholic depression: preliminary findings. European Psychiatry 21, 361363.
Montgomery, SA, Asberg, M (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry 134, 382389.
Mur, M, Portella, MJ, Martinez-Aran, A, Pifarre, J, Vieta, E (2009). Influence of clinical and neuropsychological variables on the psychosocial and occupational outcome of remitted bipolar patients. Psychopathology 42, 148156.
Murphy, FC, Michael, A, Robbins, TW, Sahakian, BJ (2003). Neuropsychological impairment in patients with major depressive disorder: the effects of feedback on task performance. Psychological Medicine 33, 455467.
O'Brien, JT, Lloyd, A, McKeith, I, Gholkar, A, Ferrier, IN (2004). A longitudinal study of hippocampal volume, cortisol levels, and cognition in older depressed subjects. American Journal of Psychiatry 161, 20812090.
Owen, AM, Downes, JJ, Sahakian, BJ, Polkey, CE, Robbins, TW (1990). Planning and spatial working memory following frontal lobe lesions in man. Neuropsychologia 28, 10211034.
Owen, AM, Sahakian, BJ, Semple, J, Polkey, CE, Robbins, TW (1995). Visuo-spatial short-term recognition memory and learning after temporal lobe excisions, frontal lobe excisions or amygdalo-hippocampectomy in man. Neuropsychologia 33, 124.
Porter, RJ, Gallagher, P, Thompson, JM, Young, AH (2003). Neurocognitive impairment in drug-free patients with major depressive disorder. British Journal of Psychiatry 182, 214220.
Potter, GG, Kittinger, JD, Wagner, HR, Steffens, DC, Krishnan, KRR (2004). Prefrontal neuropsychological predictors of treatment remission in late-life depression. Neuropsychopharmacology 29, 22662271.
Poznanski, EO, Cook, SC, Carroll, BJ (1979). A depression rating scale for children. Pediatrics 64, 442450.
Purcell, R, Maruff, P, Kyrios, M, Pantelis, C (1997). Neuropsychological function in young patients with unipolar major depression. Psychological Medicine 27, 12771285.
Reppermund, S, Ising, M, Lucae, S, Zihl, J (2009). Cognitive impairment in unipolar depression is persistent and non-specific: further evidence for the final common pathway disorder hypothesis. Psychological Medicine 39, 603614.
RevMan (2011). Review Manager (RevMan), Version 5.1. The Nordic Cochrane Centre, The Cochrane Collaboration: Copenhagen.
Robbins, TW, James, M, Owen, AM, Sahakian, BJ, McInes, L, Rabbitt, PMA (1994). Cambridge Neuropsychological Test Automated Battery (CANTAB): a factor analytic study of a large sample of normal elderly volunteers. Dementia 5, 266281.
Rogers, RD, Blackshaw, AJ, Middleton, HC, Matthews, K, Hawtin, K, Crowley, C, Hopwood, A, Wallace, C, Deakin, JFW, Sahakian, BJ, Robbins, TW (1999). Tryptophan depletion impairs stimulus-reward learning while methylphenidate disrupts attentional control in healthy young adults: implications for the monoaminergic. Psychopharmacology 146, 482491.
Roiser, JP, Elliott, R, Sahakian, BJ (2012). Cognitive mechanisms of treatment in depression. Neuropsychopharmacology 37, 117136.
Sahakian, BJ, Jones, G, Levy, R, Gray, J, Warburton, DM (1989). The effects of nicotine on attention, information processing, and short-term memory in patients with dementia of the Alzheimer type. British Journal of Psychiatry 154, 797800.
Sahakian, BJ, Morris, RG, Evenden, JL, Heald, A, Levy, R, Philpot, M, Robbins, TW (1988). A comparative study of visuospatial memory and learning in Alzheimer-type dementia and Parkinson's disease. Brain 111, 695718.
Sahakian, BJ, Owen, AM, Morant, NJ, Eagger, SA, Boddington, S, Crayton, L, Crockford, HA, Crooks, M, Hill, K, Levy, R (1993). Further analysis of the cognitive effects of tetrahydroaminoacridine (THA) in Alzheimer's disease: assessment of attentional and mnemonic function using CANTAB. Psychopharmacology 110, 395401.
Snyder, HR (2013). Major depressive disorder is associated with broad impairments on neuropsychological measures of executive function: a meta-analysis and review. Psychological Bulletin 139, 81132.
Solé, B, Bonnin, C, Torrent, C, Balanzá-Martinez, V, Tabarés-Seisdedos, R, Popovic, D, Martinez-Arán, A, Vieta, E (2012). Neurocognitive impairment and psychosocial functioning in bipolar II disorder. Acta Psychiatrica Scandinavica 125, 309317.
Stefanopoulou, E, Manoharan, A, Landau, S, Geddes, JR, Goodwin, G, Frangou, S (2009). Cognitive functioning in patients with affective disorders and schizophrenia: a meta-analysis. International Review of Psychiatry 21, 336356.
Story, TJ, Potter, GG, Attix, DK, Welsh-Bohmer, KA, Steffens, DC (2008). Neurocognitive correlates of response to treatment in late-life depression. American Journal of Geriatric Psychiatry 16, 752759.
Swainson, R, Hodges, JR, Galton, CJ, Paykel, ES, Semple, J, Michael, A, Dunn, BD, Iddon, JL, Robbins, TW, Sahakian, BJ (2001). Early detection and differential diagnosis of Alzheimer's disease and depression with neuropsychological tasks. Dementia and Geriatric Cognitive Disorders 12, 265280.
Sweeney, JA, Kmiec, JA, Kupfer, DJ (2000). Neuropsychologic impairments in bipolar and unipolar mood disorders on the CANTAB neurocognitive battery. Biological Psychiatry 48, 674684.
Taylor Tavares, JV, Clark, L, Cannon, DM, Erickson, K, Drevets, WC, Sahakian, BJ (2007). Distinct profiles of neurocognitive function in unmedicated unipolar depression and bipolar II depression. Biological Psychiatry 62, 917924.
Tsaltas, E, Kalogerakou, S, Papakosta, V-M, Kontis, D, Theochari, E, Koutroumpi, M, Anyfandi, E, Michopoulos, I, Poulopoulou, C, Papadimitriou, G, Oulis, P (2010). Contrasting patterns of deficits in visuospatial memory and executive function in patients with major depression with and without ECT referral. Psychological Medicine 41, 983995.
Veiel, HO (1997). A preliminary profile of neuropsychological deficits associated with major depression. Journal of Clinical and Experimental Neuropsychology 19, 587603.
Weiland-Fiedler, P, Erickson, K, Waldeck, T, Luckenbaugh, DA, Pike, D, Bonne, O, Charney, DS, Neumeister, A (2004). Evidence for continuing neuropsychological impairments in depression. Journal of Affective Disorders 82, 253258.
Weissman, MM, Bland, RC, Canino, GJ, Faravelli, C, Greenwald, S, Hwu, H, Joyce, PR, Karam, EG, Lee, C, Lellouch, J, Newman, SC, Rubio-Stipec, M, Wells, JE, Wickramaratne, PJ, Wittchen, H, Yeh, E (2010). Cross-national epidemiology of major depression and bipolar disorder. Journal of the American Medical Association 276, 293299.
Zakzanis, KK, Leach, L, Kaplan, E (1998). On the nature and pattern of neurocognitive function in major depressive disorder. Neuropsychiatry, Neuropsychology, and Behavioral Neurology 11, 111119.


Related content

Powered by UNSILO
Type Description Title
Supplementary materials

Rock supplementary figures
Rock supplementary figures

 Word (599 KB)
599 KB

Cognitive impairment in depression: a systematic review and meta-analysis

  • P. L. Rock (a1) (a2), J. P. Roiser (a3), W. J. Riedel (a1) (a4) (a5) and A. D. Blackwell (a1) (a4)


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.