Brain-Training Programs May Improve Cognition in Patients With Bipolar Disorder

Computer-based brain training can boost cognition in people with bipolar disorder, potentially improving their daily functioning and quality of life, according to a study published October 17 in the Journal of Clinical Psychology.

McLean Hospital

“There has been no previous effective treatment for cognitive symptoms in bipolar patients, and medications are not helpful for cognitive deficits,” said Kathryn Eve Lewandowski, Ph.D., an assistant professor of psychology at Harvard Medical School. She and colleagues found that bipolar patients who participated in a computerized brain-training program experienced significant improvements in overall cognitive performance as well as processing speed, visual learning, and memory compared with patients who played computer games.

Lewandowski, director of clinical programming at McLean Hospital in Belmont, Mass., said clinicians should consider introducing this brain training in the “recovery phase” (as opposed to initial sessions) of therapy as an adjunctive activity when patients are relatively stable and better able to initiate and stay with treatment. “It’s convenient for patients because they don’t have to go into a clinic but still have the ability to engage in these exercises on a regular basis,” she said, adding that the programs such as the one used in her study are available on a monthly subscription service.

Study participants were enrolled through the McLean Hospital Schizophrenia and Bipolar Disorder Program between July 2011 and November 2015. Seventy-five patients aged 18 to 50 years with a DSM-IV diagnosis of bipolar I disorder and a history of psychosis were randomly assigned to a 70-hour computer cognitive remediation program or an Internet-based control intervention over a period of 24 weeks (about three sessions per week).

Cognitive scores, medication dosage, number of medications or proportion of patients on any given class of medication were similar between the two groups. Patients in the cognitive remediation group and control group were taking an average of 2.7 and 3.1 psychiatric medications, respectively: 93 percent were taking a mood stabilizer, 69 percent were taking lithium, 70 percent were taking an antipsychotic, 34 percent were taking an antidepressant, and 23 percent were taking a benzodiazepine.

The treatment group had access to BrainWorks programs from PositScience, manufacturer of the Brain HQ online exercises and apps. The games were developed based on a recovery model of neural plasticity, using a “bottom up” approach to train sensory processing during the early weeks of training, then adding higher-order tasks as the program progressed, according to the study. Games included basic auditory and visual perception, tasks of divided attention, memory games, and problem-solving.

For the control group, the researchers developed an Internet-based intervention, consisting of quiz-type computer games, which did not use the same kind of structured program designed to strengthen sensory processing and higher cognitive skills in a systemized way.

Researchers included only patients with a history of psychosis for two main reasons: (1) to reduce heterogeneity of the sample, considering the variability of symptoms within bipolar disorder; and (2) a history of psychosis in patients with bipolar disorder may be associated with more severe cognitive deficits.

Cognitive dysfunction is a core symptom in bipolar disorder as well as schizophrenia and other psychiatric disorders, and one that may predict a patient’s ability to thrive in a community. Because a previous study had shown that this type of remediation improved cognitive functioning in patients with schizophrenia, Lewandowski said she felt confident that the same would hold true for patients with bipolar disorder.

Cognitive assessments were conducted at baseline, at midpoint (after 20 to 25 hours of training), posttreatment, and after six months of no study contact.

Cognitive remediation produced robust effects on cognition in the treatment group compared with the control group, but the control group also showed increased cognition in several domains. However, only the treatment group maintained this higher level of cognitive performance at six months, according to the study.

Additionally, based on previous work using this cognitive-remedial program on people with schizophrenia, the treatment effect on visual learning and memory at posttreatment was even stronger than expected, according to the authors. “The version of the CR paradigm we used included activities that explicitly train basic and complex visual processing, interweaved with the auditory training, which may have generated additional benefits in visual learning and memory,” they wrote.

Lewandowski’s team is now involved in two new projects that follow up this study. First, the researchers will look at the individuals who responded well to the training and those who did not. “Not everyone gets better,” she said. “We’re interested in identifying who does. We want to know the characteristics of patients who are likely to benefit.” Second, the team will analyze neuroimaging data (fMRI) that was taken before and after the training to see if they can find changes in the brain associated with response to the therapy.

The study was funded by the National Institute of Mental Health. PositScience provided the cognitive-remedial training software for research purposes free of charge. ■