COGNITIVE REMEDIATION IN PATIENTS WITH BIPOLAR DISORDER

INTRODUCTION
Patients with chronic psychiatric disorders have been found to have significant
cognitive deficits. Cognition is now widely considered a core deficit in these
disorders. Cognitive remediation for cognitive impairment in patients with
mood disorders has gained interest in recent years. This paper presents
research documenting the effectiveness of computer assisted cognitive
remediation for patients with mood disorder, especially patient with bipolar
disorder (BD) . Cognitive remediation therapies aim to improve the cognition of
patients and promote a better functional outcome. CogPack, a computer-based
cognitive remediation software, is one clinical tool developed to improve
cognition. Precedent studies showed its efficacy regarding attention, verbal
learning and problem solving in patient with schizophrenia. The aim of this
study was to evaluate the cognitive processes following cognitive remediation
in a sample of patients suffering from Bipolar Disorder. The purpose of this
research is discussing for the future clinical implications and applications of
the main findings.

COGPACK
It is a widely used computer based cognitive remediation software offering a
variety of exercises with various degree of difficulty. Four modules were
selected for this study:
Attention and Concentration : based on pattern comparison method. The
patient is given a target picture, and asked to find the matching one from a set.
It requires concentration, selective attention and visual exploration.
Divided attention : training environment in the context of engine driving, the
patient asked to check the driver’s cab, regulate the speed and react
appropriately to different signals. This procedure requires attention and
alertness.
Logical Reasoning : the patient is asked to complete a series of figures and in
doing so find the logical rule. This exercise requires abstract thinking and
problem solving skills.
Verbal Memory : the patient is presented with short stories, each of which
contains target information to recall. The aim of the procedure is to improve
short and long term memory skills and teach the patient structured encoding
strategies.

METHODS
Design: The study procedures agreed with institutional ethical approval.
Patients who agreed to take part in the study completed written, informed
consent and were assigned to the treatment group or control group. Patients
were assessed before and after treatment on neuropsychological test battery
conducted by trained neuropsychologist who were blind to the treatment
condition of the participants. Neuropsychological testing and scoring was
supervised by a neuropsychologist.

Participants : This study examined the effectiveness of computer-assisted

cognitive remediation on 65 patients diagnosed with psychotic disorders at
Mayo Clinic. 40 patients (male and female, aged between 18 and 50 years)
with a diagnosis of Bipolar Disorder according to DSM-IV diagnostic criteria and
in pharmacological treatment, were recruited. Any case of neurological
disorders, toxic or alcohol abuse, psychiatric comorbidity led to participants'
exclusion. A group of healthy control subjects were composed from 25 subjects
participated to the study, these subjects were tested with the same cognitive
assessment of the treatment group but they did not participate in the cognitive
treatment.

Procedures:

Cognitive assessment :
A standardized neuropsychological battery is administered to all the subjects.
Patients and the group of healthy control subjects were tested on a battery of
neuropsychological tasks at a baseline time-point (PRE), following the
treatment (POST: approximately 3 months after baseline testing). The group of
healthy control subjects were tested using the same neuropsychological
battery at the same two time points to control for test effects in the patient
sample. These subjects did not participate in the cognitive treatment.
The following cognitive variables were chosen to asses the efficacy of the
cognitive training:
 General efficiency: Wechsler Adult Intelligence Scale (WAIS)
 Speed of processing: Trail Making Test-Part A.
 Executive functions and Logical Reasoning: Wisconsin Card Sorting Test
(WCST).
 Verbal Learning and Memory: California Verbal Learning Test and Free and
Cued Reminding / Recall / Test.

The treatment group (N = 40) cognitive assessment (PRE) + treatment +

cognitive assessment (POST)
Control subjects (N = 25) just two cognitive assessment (first in baseline and
the second after approximately 3 months)

Cognitive remediation with “CogPack” : (see the specific topic above) The
cognitive training consisted of two 30-minute sessions per week. The total
number of sessions are 15 for each patient . The therapy was conducted by a
neuropsychologist technologist using a computer remediation software
(CogPack).
Statistical method : In order to compare neuropsychological results, before
and after cognitive remediation for each patient, a two-tailed Student t-test
(paired sample analysis) was used.

RESULTS
The treatment group (N = 40) showed significant improvement on most tests of
the Wechsler intelligence Scale, as well as on the Trail making Test (Parts A),
and reported significantly fewer cognitive complaints. Control subjects (N = 25)
showed no changes on these variables. These results indicate that psychiatric
patients can productively work with computers, and that computer-assisted
cognitive remediation can produce short-term improvements in psychiatric
patients' cognitive performance.

It results that computer-assisted remediation enhanced cognitive efficiency

with a mean effect size of 0.28 (according to guidelines it is a large effect size)
with confidence interval (CI) of 0.20–0.33. Improvements were also significant
in Verbal Learning and Memory, Executive-function and Speed of Processing
with small effect sizes.

DISCUSSION
This study to assess the efficacy to the cognitive stimulation software CogPack
in a group of 40 patients suffering from BD. The findings show significant short-
term improvement in all cognitive variables. Computer-based exercises are
often widely used in rehabilitation , they should be patient-therapist "ready
made" stimulation software so it can become a tool to improve the cognitive
functioning of the patient used in hospitals, in clinic or by the patient himself
or herself. So this study can be use to draw up guideline, so it would be
recommend:
 a clear formulation of patient's cognitive performance status to decide
the right “ad hoc” computer-assisted treatment.
 The aim of each session is to remain strictly linked to real life situations
and see the patient's progress in the light of the real life experiences.
 It's important to motivate, engage and involve the patient in the
computer-assisted exercises.

Limitations and suggestions for further research:

This study observes a short-term improvement in Bipolar Disorder patients'
cognitive performance, but a long-term follow-up would be useful to evaluate
the long lasting effect of cognitive remediation on cognitive processes. For
example should be interesting to test the same subjects 1 year later the
treatment.
Conclusion:
The results support the efficacy of computer-assisted remediation fixing
cognitive impairment. These findings highlight the active role of both therapist
and patient during computer-assisted cognitive remediation therapy. The
remediation software can be useful to the neuropsychologist to coadiuvate
other treatments ( cognitive and behavioural therapies, medications, social
skills learning, etc.). Computer-assisted remediation can be adapted from
patient to patient // patient-to-patient.

REFERENCES

D'Amato et al. (2011). A randomized, controlled trial of computer-assisted

cognitive remediation for schizophrenia. Schizophrenia research, 125, 284-290.
Martinez-Aràn A, Vieta E, Colom F, Reinares M et al. Cognitive Dysfunctions in
bipolar disorder: evidence of neuropsychological disturbances. Psychother
Psychosom 2000;69(1):2-18

Muller-Oerlinghausen B, Berghofer A, Bauer M. Bipolar Disorder. Lancet 2002;

359: 241-47

Bearden CE, Hoffman KM, Cannon TD. The neuropsychology and neuroanatomy
of bipolar affective disorder: a critical review. Bipolar Disorders 2001:3:106-150
Pattanayak RD, Sagar R, Mehta M. Neuropsychological performance in
euthymic Indian patients with bipolar disorder type I: correkation between
quality of life and global functioning. Psychiatry and Clin Neurosci 2012;66:553-
563
Sole B, martinez-Aran A, Torrent C, Bonnin CM, Reinares M, Popovic D. Are
bipolar II patients cognitively impaired? A systematic review. Psychological Med
2011;41:1791-1803
Whitley R, Drake RE. Recovery: a dimensional approach. Psychiatr Serv 2010
Dec;61(12):1248-50
Preiss M, Shatil E, Cermakova R, Cimermanova D, Ram I. Personalized cogntiive
training in unipolar and bipolar disorder: a study of cognitive functioning. Front
Hum Neurosci 2013; May(7) article 108
Demant KM, Almer GM, Vinberg M, Kessing LV, Miskowiak KW. Effects of
cognitive remediation on cognitive dysfunction in partially or fully remitted
patients with bipolar disorder: study protocol for a randomized controlled trial.
Trials 2013, 14:378
Bellivier F, Golmard JL, Rietschel M, Schulze TG, et al. Age at onset in bipolar I
affective disorder: further evidence for three subgroups. Am J Psychiatry, 2003;
160:999-1001
Craddock N, Sklar P. Genetics of Bipolar Disorder. Lancet, 2013; 381:1654-62;
Geddes JR & Miklowitz DJ. Treatment of bipolar disorder. Lancet, 2013 May
11;381(9878);
Wingo AP, Baldessarini RJ, Holtzheimer PE, Harvey PD. Factors associated with
functional recovery in bipolar disorder patients. Bipolar Dis 2010, 12:319-326
Sole B, Bonnin CM, Torrent C, Martinez-Aran A, Popovic D, tabares-Seisdedos,
Vieta E. Neurocognitive Impairment across the bipolar spectrum. CNS Neurosci
Therapeutics 2012(18):194-200
American Psychiatric Association. Diagnostic and statistical manual of mental
disorders. Fifth Edition DSM-5. APA Publishing 2013
Rowland JE, Hamilton MK, Vella N, Lino BJ, Mitchell PB, Green MJ. Adaptive
associations between social cognition and emotion regulation are absent in
schizophrenia and bipolar disorder. Frontiers in Psychology 2013 Jan (3)
Wykes and Reeder (2005). Cognitive Remediation Therapy for Schizophrenia.
Theory & Practice. Routledge Eds.