Cognition

Difficulties with attention, memory, processing speed, planning and problem solving are common concerns for people with bipolar disorder. These functions fall under the umbrella of ‘cognition:’ the process of acquiring, understanding and using information about the world around us. Cognition is made up of a number of individual domains such as memory, attention, language, visual-spatial skills, planning, problem solving and processing speed (the speed at which people understand and respond to information).

We are all born with different cognitive capabilities. Cognitive skills can change over our lifetimes. Some cognitive skills may worsen with illness, injury or age; at other times, cognitive skills can become strengthened or improved.

Key Messages

What to know about cognition:

  • Cognitive problems most pronounced in severe mood episodes
  • A primary symptom of bipolar disorder, not just related to mood symptoms
  • Impacted by age, medications, substance misuse, sleep problems

Why cognition is important to your quality of life

Cognition is essential for independent living and regular activities – in other words, you are using it daily! For example, to make a coffee date with a friend, you might need to a) pay attention to them on the phone, b) understand what they say, c) think about your schedule and organize a time to meet, d) remember this date and e) plan how to get there.

Cognitive skills are necessary to succeed in work, school, parenting, completing household activities, and leisure activities. They’re important in maintaining relationships—friends and family value someone who pays attention to them, remembers things about them and follows through on plans to get together. It’s not a surprise, then, that research studies have linked cognitive function to quality of life in people living with bipolar disorder1. We’ve learned that cognitive problems are a primary symptom of bipolar disorder, and not just related to mood symptoms2.

A young white man standing in front of a bulletin board covered in different pages of diagrams and plans.

Cognitive functioning in bipolar disorder

Research has shown that cognition does appear to be impacted in people with bipolar disorder. At a group level, people with bipolar disorder on average perform poorer on cognitive tests compared to groups without a psychiatric diagnosis, even if they are not currently experiencing mood symptoms3. This is seen across multiple cognitive domains, including memory, attention, processing speed and planning/problem solving. Studies have also shown that cognition is a significant contributor to real-world functioning in people with mood disorders4. In other words, people with more severe cognitive problems tend to struggle more in accomplishing activities of daily life. Cognitive problems can be most obvious during mood episodes, especially severe depression or mania5. However, they can even continue afterwards when you’re not experiencing any mood symptoms. Recreational drugs, alcohol or substance misuse can be associated with more cognitive problems6 – see the Physical section for more information. Additionally, sleep problems (a common symptom of bipolar disorder; see Sleep section) can lead to problems in cognition7.

All the above would suggest that: 1) bipolar disorder is associated with cognitive problems, 2) these problems may persist even when mood is stable, and 3) they may impact a person’s functioning and quality of life. However, while we recognize the importance of cognitive symptoms in bipolar disorder, we also need to guard against adopting too bleak an outlook. First, not all patients with bipolar disorder meet an accepted threshold of cognitive ‘impairment’, and a sizable proportion of people with bipolar disorder have normal to above-normal cognitive abilities8,9. So while bipolar disorder is associated with cognitive problems on a group level, many individuals with bipolar disorder are cognitively ‘well’. Additionally, a bipolar disorder diagnosis does not lead to a lifetime of progressive cognitive decline. Studies that have tracked individuals with bipolar disorder have generally failed to support the idea that cognitive problems get worse over time. In fact, if well treated, individuals may show improvements over time in memory, working memory and processing speed10,11.

Medication and cognitive effects

Medications may have some cognitive side effects too. It can be hard to know if cognitive symptoms are related to your bipolar disorder or to your medications, especially as medications are often started right when the symptoms of bipolar disorder are first recognized. Side effects from different medications are not the same; some medications may have minor cognitive side effects and others have few, if any. Some recent research studies even report the potential for cognitive protection, or improvement, with certain medications12.

Cognitive side effects also may increase as the dose of your medication is increased, so it’s important to find the right dose of medication that provides the best balance for your mood with the lowest risk for side effects. As everyone responds to medications differently, this dose will be different for everyone: some people are sensitive to side effects, while others are not. Another thing to keep in mind is drug interactions (i.e., how two or more drugs act when taken together). Multiple medications taken together may interact to produce more side effects than each medication alone. So, caution may be needed, especially if you have more than one doctor prescribing medications for you, take medications differently than prescribed, or take over-the-counter medications.

A young woman with brown skin and dark hair playing a game of chess.

How you can take action

By learning about the possible cognitive effects of bipolar disorder and your medications, you can learn to recognize cognitive symptoms and better manage your condition to improve your quality of life and ability to do your daily activities.

The first step is realize that you may be experiencing cognitive problems so you can recognize any cognitive changes or problems. Some people find it useful to track changes in memory, attention, alertness and thinking, to see how cognition may change with different medications or during different mood phases2. It can be helpful to have someone else, such as a family member or healthcare professional, also track these changes, as cognitive problems may be recognized easier by someone else.

Report any changes in cognition that you (or your family) notice to your doctor and healthcare team. This will help you work with them to see if there may be changes in medications that could help you, without destabilizing or upsetting the balance of your mood. Remember that medication changes are based on complex decisions, so be cautious about changing medications or doses without a doctor’s help. Also, be sure to share information with your healthcare team about recreational substances you may be using, other medications you are taking or changes in the way you’re taking medications– this all may lead to drug interactions and cognitive problems. As a step toward better understanding your cognitive problems, referral for a more comprehensive evaluation may be necessary.

If, together with your healthcare team, you’ve come to the conclusion that you have cognitive challenges that have little to do with medications, you may want to try some of the following cognitive rehabilitation strategies. There are few treatments specifically targeting cognition in people with bipolar disorder. No medication has yet shown reliable enough cognitive-enhancing effects to be routinely recommended. However, cognitive rehabilitation , which addresses common cognitive deficits, has been shown to improve real-world functioning13. These are therapies involving activities that help restore cognition (i.e., your thinking skills) to a healthier state. Although formal, therapist-led cognitive rehabilitation programs for bipolar disorder may not yet be available in all locations, you and your healthcare professional can discuss adapting the techniques used in cognitive rehabilitation into your life. Cognitive rehabilitation includes managing cognitive problems with three different methods: remediation techniques, compensatory strategies and adaptive approaches. Having an assessment or evaluation by a healthcare professional can help you decide which unique approach may be most helpful for you.

An older East Asian man sitting at the counter of a convenience store, looking down as if he is in thought.

Remediation techniques help improve thinking with drills and exercises that may involve computers, paper and pencil, or group activities2. It’s important to have a formal assessment and make a treatment plan specific to your own needs to guide your training. Remediation techniques don’t offer a quick fix: progress takes time and effort. Research is in its infancy for remediation techniques, but research studies are showing promising results for cognitive training in people with mood disorders, including some with bipolar disorder14,15. While you may improve your results on the specific tasks you practice, it’s still uncertain how helpful this will be to your overall functioning16.

Compensatory strategies help you come up with different ways to accomplish your goals; to help you ‘compensate’ or make up for cognitive challenges. For example, you can learn mnemonics (or ‘memory aids’) to help you remember things. Let’s say you need to remember three things to buy at the grocery store — milk, eggs and butter. You can make a catchy phrase using the first letters of each item to help you remember them. For example, ‘My ear is blue’ – a catchy phrase that makes a picture in your mind of you with a blue ear, with the first letter of each word standing for one of the things you need to buy – my – M for milk, ear – E for eggs, blue – B for butter – makes it much easier to remember what to buy when you get to the store. The use of compensatory strategies and their application to real life situations can also be an important component to therapies aimed at improving cognition. In fact, the most promising therapies may involve both the use of cognitive exercises as well as group based activities aimed at applying learned strategies to daily situations17.

Adaptive approaches try to change your environment (i.e., the world around you). You might try having a recording device to help you keep track of important information. Or you might set timers to remind you to do certain activities.

Take Action

Ways that you can take action:

  • Watch for cognitive changes/problems; allow others to help monitor for them
  • Report changes in cognition to healthcare providers
  • Consider cognitive rehabilitation strategies if needed

Quick tips to support cognition

Finally, here’s a list of useful and easy to implement tips that can help you and your supports adapt to cognitive challenges you may be experiencing:

  • Keep communication and activities simple, direct, and short
  • Keep activities to one thing at a time; try not to multi-task
  • Make sure that you rest; fatigue can make cognitive problems worse
  • Try to limit distractions
  • Try to balance activities so that you have a blend of physical, mental and social activities to keep your interest up and prevent fatigue
  • Try to keep activities and tasks structured and organized

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References

  1. Mackala, S.A., Torres, I.J., Kozicky, J., Michalak, E.E., & Yatham, L.N. (2014). Cognitive performance and quality of life early in the course of bipolar disorder.  Journal of Affective Disorders, 168C: 119-124.
  2. Medalia, A. & Revheim, N. (2002). Dealing with Cognitive Dysfunction Associated with Psychiatric Disabilities.  New York State Office of Mental Health.  Available at http://www.omh.state.ny.us/omhweb/resources 
  3. Bora et al. (2009).  Cognitive Endophenotypes of Bipolar Disorder: A Meta-Analysis of Neuropsychological Deficits in Euthymic Patients and Their First-Degree Relatives.  Journal of Affective Disorders: 113(1-2), 1 – 20.
  4. Bonnín, C. del M., Reinares, M., Martínez-Arán, A., Sánchez-Moreno, J., Solé, B., Montejo, L., & Vieta, E. (2019). Improving Functioning, Quality of Life, and Well-being in Patients With Bipolar Disorder. International Journal of Neuropsychopharmacology, 22(8), 467–477. https://doi.org/10.1093/ijnp/pyz018 
  5. Torres, I.J., & Malhi, G.S. (2010). Neurocognition in bipolar disorder. In: Yatham, L.N. & Maj, M. (Eds.) (2011). Bipolar disorder: clinical and neurobiological foundations, pg.71. John Wiley & Sons.
  6. Cardoso, T. de A., Bauer, I. E., Jansen, K., Suchting, R., Zunta-Soares, G., Quevedo, J., Glahn, D. C., & Soares, J. C. (2016). Effect of alcohol and illicit substance use on verbal memory among individuals with bipolar disorder. Psychiatry Research, 243, 225–231. https://doi.org/10.1016/j.psychres.2016.06.044 
  7. Kanady, J. C., Soehner, A. M., Klein, A. B., & Harvey, A. G. (2017). The association between insomnia-related sleep disruptions and cognitive dysfunction during the inter-episode phase of bipolar disorder. Journal of Psychiatric Research, 88, 80–88. https://doi.org/10.1016/j.jpsychires.2017.01.001 
  8. Burdick, K. E., Russo, M., Frangou, S., Mahon, K., Braga, R. J., Shanahan, M., & Malhotra, A. K. (2014). Empirical evidence for discrete neurocognitive subgroups in bipolar disorder: Clinical implications. Psychological Medicine, 44(14), 3083–3096. https://doi.org/10.1017/S0033291714000439a 
  9. Lima, F., Rabelo-da-Ponte, F. D., Bücker, J., Czepielewski, L., Hasse-Sousa, M., Telesca, R., Solé, B., Reinares, M., Vieta, E., & Rosa, A. R. (2019). Identifying cognitive subgroups in bipolar disorder: A cluster analysis. Journal of Affective Disorders, 246, 252–261. https://doi.org/10.1016/j.jad.2018.12.044 
  10. Bora, E., & Özerdem, A. (2017). Meta-analysis of longitudinal studies of cognition in bipolar disorder: Comparison with healthy controls and schizophrenia. Psychological Medicine, 47(16), 2753–2766. https://doi.org/10.1017/S0033291717001490 
  11. Torres, I. J., Qian, H., Basivireddy, J., Chakrabarty, T., Wong, H., Lam, R. W., & Yatham, L. N. (2020). Three-year longitudinal cognitive functioning in patients recently diagnosed with bipolar disorder. Acta Psychiatrica Scandinavica, 141(2), 98–109. https://doi.org/10.1111/acps.13141
  12. Sole, B., Bonnin, C. M., Torrent, C., Martinez-Aran, A., Popovic, D., Tabarés-Seisdedos, R., & Vieta, E. (2012). Neurocognitive impairment across the bipolar spectrum. CNS Neuroscience & Therapeutics, 18(3), 194–200. https://doi.org/10.1111/j.1755-5949.2011.00262.x 
  13. Torrent, C., Bonnin, C. del M., Martínez-Arán, A., Valle, J., Amann, B. L., González-Pinto, A., Crespo, J. M., Ibáñez, Á., Garcia-Portilla, M. P., Tabarés-Seisdedos, R., Arango, C., Colom, F., Solé, B., Pacchiarotti, I., Rosa, A. R., Ayuso-Mateos, J. L., Anaya, C., Fernández, P., Landín-Romero, R., … Vieta, E. (2013). Efficacy of functional remediation in bipolar disorder: A multicenter randomized controlled study. The American Journal of Psychiatry, 170(8), 852–859. https://doi.org/10.1176/appi.ajp.2012.12070971 
  14. Bowie, C.R., Gupta, M., & Holshausen, K. (2013). Cognitive remediation therapy for mood disorders: Rationale, early evidence, and future directions. Canadian Journal of Psychiatry, 58: 319-325.
  15. Lewandowski, K. E., Sperry, S. H., Cohen, B. M., Norris, L. A., Fitzmaurice, G. M., Ongur, D., & Keshavan, M. S. (2017). Treatment to Enhance Cognition in Bipolar Disorder (TREC-BD): Efficacy of a Randomized Controlled Trial of Cognitive Remediation Versus Active Control. The Journal of Clinical Psychiatry, 78(9), e1242–e1249. https://doi.org/10.4088/JCP.17m11476 
  16. Owen, A., Hampshire, A., Grahn, J.A., Stenton, R., Dajani, S., Burns, A.S., Howard, R., & Ballard, C.G. (2010).  Putting Brain Training to the Test.  Nature,  465(7299): 775-778.
  17. Bellani, M., Biagianti, B., Zovetti, N., Rossetti, M. G., Bressi, C., Perlini, C., & Brambilla, P. (2019). The effects of cognitive remediation on cognitive abilities and real-world functioning among people with bipolar disorder: A systematic review: Special Section on ‘Translational and Neuroscience Studies in Affective Disorders’.  Journal of Affective Disorders, 257, 691–697. https://doi.org/10.1016/j.jad.2019.07.059