Cognitive impairment is an affliction for many people with bipolar disorder, and affects domains including executive function, attention, memory (particularly verbal memory), and social cognition. These deficits interfere considerably with day-to-day function.

Cognitive remediation (or rehabilitation) interventions usually take the form of repetitive exercises with or without computers and sometimes augmented by group sessions, strategy coaching and homework exercises, which serve as training for cognitive processes such as memory or attention, as well as social skills and communication. Strategy learning focuses on providing alternative strategies to compensate for the observed difficulties with cognition; in contrast, rehearsal learning is aimed at restitution of lost skills. This type of intervention is specifically targeted to particular cognitive domains which are known to be deficient in people with bipolar disorder, with the intention of compensating or improving functional outcome.

What is the evidence for cognitive remediation?

Low quality evidence is unable to determine any benefits of cognitive rehabilitation for people with bipolar disorder. Review authors report that findings were not robust due to the variety of intervention designs, the methodological limitations of the studies, and the lack of studies in the field.

November 2021

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Cognitive symptoms of schizophrenia have been found in all cognitive domains, including executive function, memory, and attention, and often develop prior to the other symptoms of schizophrenia. They are highly disabling and predict poor functional outcomes.

What is the evidence for treatments for cognitive symptoms?

Overall, moderate to high quality evidence suggests second-generation antipsychotics are associated with small improvements in processing speed, verbal fluency, learning, motor skills, long-term memory, and global cognition when compared to first generation antipsychotics, but have no benefit over first generation antipsychotics for improving attention, cognitive flexibility, working memory, delayed recall, or visuospatial processing. High quality evidence shows a small benefit of first-generation antipsychotics over placebo for general cognitive functioning.

For specific antipsychotics, moderate to high quality evidence shows haloperidol is associated with small improvements in global cognition (low haloperidol dose only), verbal learning (low and high dose), delayed recall (low and high dose), and attention (low dose only) when compared to second generation antipsychotics, with no differences in executive function, verbal fluency, motor skills, or processing speed. Sertindole may be superior to; clozapine, quetiapine, and first generation antipsychotics for general cognitive ability; clozapine, quetiapine, and olanzapine for memory; clozapine, quetiapine, olanzapine and ziprasidone for executive functioning; and quetiapine for processing speed. Olanzapine may be superior to clozapine and first generation antipsychotics for visuospatial skills and verbal fluency.

Moderate quality evidence finds small improvements in overall cognition after treatment with clozapine, olanzapine, quetiapine, risperidone, and ziprasidone, particularly on measures of memory, attention, processing speed, and executive functioning. Fluency was improved with clozapine, olanzapine, and quetiapine only. There were no significant improvements in visuospatial skills, language, or motor functioning.

For other agents, moderate to high quality evidence suggests small benefits of antidepressants over placebo for global cognition and executive functioning. There was a small improvement in verbal learning with adjunctive anti-dementia medications compared to placebo, with no improvements in overall cognition, memory, speed of processing, attention, problem solving, executive functioning, social cognition or visual learning. There were no differences in adverse events between anti-dementia medications and placebo. There were no benefits of varenicline compared to placebo for cognition, and varenicline may cause more nausea.

October 2020

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