Prises en charge de la symptomatologie cognitive dans les troubles bipolaires

Objectives

Cognitive impairments represent a major issue in mental health that remains understudied in clinical practice. This article aims to provide an overview of the literature on cognitive functioning in bipolar disorders. Additionally, its purpose is to highlight potential interventions that promote recovery, particularly within the bipolar “Centers of Expertise” of the Fondation FondaMental network.

Method

We conducted a literature review to explore various aspects related to cognitive issues in bipolar disorders, such as trait-related cognitive impairments, variations throughout the course of the illness, and the assessment and treatment of these cognitive deficits.

Results

In bipolar disorders, many cognitive disorders may present themselves in different ways; the literature identifies disorders of attention, psychomotor speed, executive functions, memory, emotional and social cognition, and metacognition. These cognitive disorders are present in all phases of the disease with heterogeneity between patients. This heterogeneity does not depend on whether patients have type I or type II bipolar disorders; nor does it depend on depressive, manic, or euthymic phases, although cognitive symptomatology is more intense in the acute phases. Bipolar disorders require treatment, although some treatments can have an influence on cognition, notably antipsychotics, lithium, or more general polypharmacy. The International Society for Bipolar Disorders (ISBD) Targeting Cognition Task Force developed consensual recommendations for clinicians regarding cognitive interventions in bipolar disorders. The recommendations include an objective and subjective assessment of cognition for all patients, regardless of whether partial or complete remission is achieved. Caregivers who are not neuropsychology specialists may, after a short training period, use screening tools such as the “Screen for Cognitive Impairment in Psychiatry” (SCIP) and “Cognitive Complaints in Bipolar Disorders Rating Assessment” (COBRA), and must refer patients for a more complete evaluation if any difficulties emerge. There is also an interest in regularly assessing cognition, in connection with the possibility of neurodegeneration. Indeed, there are several theories about the development of cognitive impairments in bipolar disorders in the literature. One theory suggests that neurodevelopmental factors could influence the occurrence of these disorders. On the contrary, the “neuroprogression model” postulates that allostatic load may disrupt cognitive functioning as part of a longer term degenerative process.

Discussion

The FondaMental network Centers of Expertise provide educational programs as well as interventions adapted to several aspects of psychiatric diseases, notably cognitive impairment. Patients can be provided with a complete cognitive assessment, and then directed towards appropriate therapies. The centers offer, for example, cognitive remediation for bipolar patients, with the goal of personal recovery. Cognitive remediation is a psychosocial rehabilitation treatment which consists of training cognitive functions via exercises aimed at developing problem-solving strategies that can be transferred to daily life. This treatment should lead to an improvement in patients’ quality of life and autonomy. Worldwide, there is a lack of recognized programs for people with mood disorders, including bipolar disorders. However, some studies report that cognitive remediation therapy leads to cognitive and functional improvement, despite heterogeneity in the results of these studies. Some authors of these studies recommend developing individualized and integrative treatments centered around the patients’ personal and professional projects, and targeting different psychological processes that mediate functional improvement. An ecological cognitive remediation program, called “Eco”, was recently created in France for patients with mood disorders, including bipolar disorders. This program uses paper and manipulable tools for cognitive remediation exercises that have been created specifically to support the transfer of cognitive skills into people's daily lives. It is composed of a psychoeducational module that: develops the patient's metacognitive knowledge; reduces self-stigmatization; and increases intrinsic motivation towards therapy. The program includes three cognitive training modules (on attention, memory, and executive functions), with sub-modules for specific functions, with exercises to be done in a guided session as well as occasionally at home. The order of presentation of the modules, as well as the number of sessions per sub-module, are adapted to each patient. Exercises are composed of ten levels of difficulty, and they allow patients to discover, develop, and then generalize new cognitive strategies. A final functional training module is used in conjunction with cognitive training, in order to help the transfer of the cognitive strategies developed to complex situations in daily life.

Conclusions

The combination of frequent assessments, preventive measures, and treatments should make it possible to manage cognitive symptoms and to support people living with a bipolar disorder in their recovery journey.