The recently published article ‘Location and progression of cerebral small-vessel disease and atrophy, and depressive symptom profiles: The Second Manifestations of ARTerial disease (SMART)-Medea study’ (Grool et al. Reference Grool, van der Graaf, Mali, Witkamp, Vincken and Geerlings2011) generates much interest. The authors have done justice to the topic. We take the opportunity to highlight a few scientific facts related to the study. The main aim of the authors was to study the correlation between white-matter lesions (WMLs), lacunar infarcts and atrophy with motivational and mood symptoms in patients with symptomatic atherosclerotic disease. We think that the baseline blood investigations did not include full blood count, renal profile and thyroid function test, which would help identify and exclude metabolic causes such as anaemia, uraemia and hypothyroidism or hyperthyroidism. These metabolic causes could be the reasons for features such as anhedonia, energy loss, concentration problems, depressed mood and appetite disturbance. The exclusion criteria in this study seemed to be rather loose.

We feel that the reference used to categorize and define the different types of brain infarcts was not mentioned properly. The sentence ‘We defined lacunar infarcts as infarcts of 3–15 mm in diameter and located in the frontal, parietal, temporal …’ suggests that the definition of brain infarcts was arbitrary. The most important question asked is whether the 15 mm size for the lacunar infarct was still considered as a cut-off mark. It is pertinent to mention that an earlier study debated the acceptance of 15 mm size as a criterion for lacunar infarct (Cho et al. Reference Cho, Kang, Kwon and Kim2007).

The Patient Health Questionnaire-9 is a subjective tool of assessment. The ill-defined points of the scale (i.e. ‘on several days’, ‘on more than half the days’ or ‘nearly every day’) may confuse the patients and lead to inaccurate information. We feel that a preferable method should objectively state the number of days per week for example (0 days, 1–2 days/week, 3–5 days/week, 6–7 days/week). We also wonder how the Patient Health Questionnaire-9 was filled out. In a cohort of patients with concentration problems and anhedonia, the information gathered from the patients themselves is questionable.

Overall, the paper by Grool et al. (Reference Grool, van der Graaf, Mali, Witkamp, Vincken and Geerlings2011) is an interesting article and we applaud the meticulous work of the authors and especially the editor for publishing such an informative paper.