Cognitive enhancement interventions for people with bipolar disorder: A systematic review of methodological quality, treatment approaches, and outcomes

Abstract

Background:Patients with bipolar disorder (BD) suffer from cognitive deficits across several domains. The association between cognitive performance and psychosocial functioning has led to the emergence of cognition as a treatment target.Objective: This study reviews the existing literature on cognitive enhancement interventions for people with BD, focusing on different treatment approaches and methodological quality. Methods:We conducted a systematic search following the PRISMA guidelines. Sample characteristics and main outcomes for each study and treatment characteristics for each approach were extracted. Study quality was assessed using the Clinical Trials Assessment Measure (CTAM) and Cochrane Collaboration's Risk of Bias tool by independent raters.Results: Eleven articles reporting data from seven original studies were identified encompassing 471 participants. Two treatment approaches were identified, cognitive and functional remediation. For controlled studies, methodological quality was modest (average CTAM score = 60.3), while the overall risk of bias was considered moderate. Beneficial effects on cognitive or functional outcomes were reported in the majority of studies (91%), but these findings were isolated and not replicated across studies. Key methodological limitations included small sample sizes, poor description of randomization process, high attrition rates, and participant exclusion from the analysis. Conclusions:Findings are promising but preliminary. Quality studies were few and mostly underpowered. Heterogeneity in sample characteristics, outcome measures, and treatment approaches further limit the ability to generalize findings. Adequately powered trials are required to replicate initial findings, while moderators of treatment response and mechanisms of transfer need to be explored. K E Y W O R D S bipolar disorder, cognition, cognitive remediation, functional remediation, functioning, methodological quality | 217 TSAPEKOS ET Al

Do we really need a “new” cognitive therapy for bipolar disorder? Paradigm refinements and treatment mechanisms for cognitive remediation

“…For Douglas et al, the key components of CET‐MD are psychoeducation on the importance of cognition, cognitive training with the use of strategies and transfer of the acquired skills and strategies into daily‐life activities. These are exactly the components that define compensatory CR in other populations and particularly in people with schizophrenia.…”

“…These are exactly the components that define compensatory CR in other populations and particularly in people with schizophrenia. In fact, our recent systematic review of psychological interventions targeting cognitive and functional difficulties for people with BD identified comparable treatment paradigms in the majority of the existing studies . These compensatory approaches include therapy components very similar to those suggested for the CET‐MD paradigm and fall either under the umbrella‐term CR or under a name indicating their specific therapeutic aim (eg, cognitive training, functional remediation).…”

“…Although we understand the rationale for proposing a new term to describe therapies targeting cognition in mood disorders, we believe that advancing research in the field requires decisive adjustments beyond terminology changes. An important step would be acknowledging the heterogeneity of cognitive difficulties among BD patients and addressing this issue in CR clinical trials to optimize cognitive interventions . Here we attempt to expand this discussion by considering how CR might be refined, including an examination of transfer mechanisms to advance functional outcomes.…”

“…Despite encouraging findings of benefits on both cognitive and functional outcomes, results are often inconsistent and not replicated across studies. These inconsistencies are probably attributable to cognitive heterogeneity in the samples …”

Cognitive Remediation Therapy for Patients with Bipolar Disorder: A Randomised Proof-of-Concept Trial

“…2 As well as functional impacts, a pattern of cognitive deterioration may increase episode recurrence, so improving cognitive abilities might enhance not only short-term wellbeing but potentially the future course of the disorder. 1,3,4 Cognitive Remediation Therapy (CRT) is a psychological intervention that has demonstrated reliable benefits for people with schizophrenia, improving core cognitive functioning, daily functioning, and quality-of-life as determined through extensive examination via clinical trials (efficacy, effectiveness, mechanistic) and comprehensive meta-analytic syntheses. eg5-7 There are well-documented similarities between the cognitive difficulties experienced by people with schizophrenia and bipolar disorder: they appear comparable in terms of impact and quality, although are on average less severe for patients with BD than schizophrenia and there is less evidence of a premorbid component.…”