May 9, 2018

Cognitive Remediation to Target Cognitive Deficits in Bipolar Disorder

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Kathryn Lewandowski, PhD

McLean Hospital, Belmont, and Harvard Medical School, Boston, Massachusetts​


Cognitive deficits in patients with bipolar disorder (BD) are increasingly recognized as a core symptom and an important therapeutic target. Cognitive symptoms are a strong predictor of disability, poor quality of life, and a longer recovery time after a first episode. Unfortunately, first-line treatments for BD do little to address cognitive symptoms, and some medications may even worsen them.

Cognitive remediation (CR) is a behavioral treatment aimed at targeting cognitive symptoms directly to enhance cognitive functioning. Neuroplasticity-based CR programs target cognitive systems through carefully-designed exercises that, over time and repeated trials, are believed to activate and strengthen neural systems that underpin cognitive processes. CR has been shown to produce reliable, durable cognitive improvements in patients with schizophrenia and related disorders. However, few studies have systematically assessed the effects of neuroplasticity-based CR in patients with BD.

In a recent study, my colleagues and I randomly assigned patients with BD to receive CR or an active comparison treatment. The CR group used a web-based program of neuroplasticity-informed exercises from Posit Science for a total of 70 hours over 24 weeks. These exercises use a “bottom up” approach, targeting more basic cognitive processes early in the treatment and then advancing to more complex cognitive functions later in the program. For the control group, we adapted a publicly-available, web-based quiz platform to mirror the CR condition in format and training hours.

Participants in the CR group displayed significant improvements compared to the active control group in overall cognitive performance, cognitive speed, visual learning, and memory. Notably, the CR group maintained cognitive gains and even showed continued improvements in some areas after 6 months of no active intervention. These findings suggest that CR can significantly improve cognition in patients with BD and that, once the brain is better able to perform cognitive tasks, it may continue to strengthen those processes even after active treatment is completed. Based on responses to a user feedback survey, participants reported high overall satisfaction with the CR training.

Cognitive improvement was associated with functional change across the sample; this finding was not specific to the CR condition, suggesting that cognitive gains in both groups were associated with functional improvements. Studies that incorporate explicit psychosocial rehabilitation elements or “coaching” appear to improve transfer of cognitive gains to measurable functional change.

In patients with BD—as in other psychiatric populations—CR is well-tolerated, affordable, easily accessible, and drives significant, durable cognitive change. Strong evidence supports CR as a promising intervention for targeting cognitive deficits across several populations, but clinical availability is sparse. A recent study examining the translation of CR for patients with serious mental illness from research to clinical settings found good acceptability and utilization across geographically diverse outpatient clinics, supporting increased efforts at clinical implementation. Continued research aimed at optimization and effective clinical implementation of CR will hasten the translation of this promising treatment from research intervention to clinical prime time.

Financial disclosure: Posit Science provided the CR training software free of charge for research purposes. Dr Lewandowski has no relevant personal financial relationships to report.

Category: Bipolar Disorder , Cognitive Remediation
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Related to “Treatment to Enhance Cognition in Bipolar Disorder (TREC-BD): Efficacy of a Randomized Controlled Trial of Cognitive Remediation Versus Active Control”

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