In a randomized controlled trial, a computer-based cognitive training program improved cognitive function in patients with bipolar disorder, with results lasting beyond the training period.
"Poor cognition is strongly associated with disability and poor quality of life in patients with bipolar disorder," lead investigator Kathryn Eve Lewandowski, PhD, director of clinical programming, Schizophrenia and Bipolar Disorder Program, McLean Hospital in Belmont, Massachusetts, told Medscape Medical News.
"Unfortunately, there are currently no effective, standard treatments for cognitive deficits in patients, so effective treatment options are urgently needed. Cognitive brain training has been shown to be effective in a number of patient populations, and now in bipolar disorder, which is encouraging," said Dr Lewandowski, who is assistant professor in the Department of Psychiatry, Harvard Medical School, Boston.
The study was published online October 27 in the Journal of Clinical Psychiatry.
Strengthening Neural Networks
The study included 72 adults with a DSM-IV diagnosis of bipolar disorder with psychosis. The patients were randomly allocated to receive either a cognitive remediation (CR) intervention (39 patients) involving an assortment of computer games or an active computer control (33 patients).
The CR protocol involved the BrainWorks programs by PositScience. These programs are "neuroplasticity-informed" games that use a "bottom up" approach to train sensory processing during the early weeks of training. "Higher-order" tasks are added as the program progresses, the investigators note.
The programs self-adjust on the basis of user performance to keep participants working at 80% proficiency. Games include basic auditory and visual perception activities, tasks of divided attention, memory and working memory games, and problem-solving games. Players earn points and virtual rewards for correct responses.
The CR group was asked to perform the computerized exercises for a total of 70 hours over 24 weeks. The active control group was asked to spend the same amount of time on computerized exercises that focused on quiz-style games, such as identifying locations on maps, solving basic math problems, and answering questions about popular culture.
Completion rates varied within groups but did not vary significantly between groups. The CR group completed an average of 43 hours, and the control group completed an average of 48 hours.
CR showed "medium to large effects" on processing speed (d = 0.42), visual learning and memory (d = 0.92), and the composite (d = 0.80), the investigators report. The superiority of CR over control on processing speed (d = 0.65) and composite (d = 0.83) persisted 6 months after the end of training, with a slight further improvement.
"Our finding that cognitive improvements persisted 6 months after the end of the computer training supports the idea that once the brain is better at performing cognitive tasks, it will maintain or even continue to strengthen these processes over time," said Dr Lewandowski.
CR was not associated with a significant change in functioning, but participants with the largest cognitive improvements showed the largest gains in functioning across the sample.
"Computerized brain training is believed to drive improvements in cognition through repeated use of carefully designed cognitive activities that modify neural networks through neuroplasticity. Over time and repeated trials, this intensive training is designed to activate and strengthen neural systems that underpin cognitive processes," Dr Lewandowski said.
"Replication of our findings would be helpful in deciding how best to implement cognitive training clinically, as would clear guidelines on effective dosing strategies," she added.
She also noted that patients seemed to enjoy the brain training program. "User feedback was positive overall, with subjects reporting that they were glad they participated in the training and would recommend this treatment to others," Dr Lewandowski said.
Noteworthy Study With Caveats
"This study is novel because, using a well-controlled, randomized design, they found that a cognitive remediation program developed to help people with schizophrenia also had some specific benefit for people with bipolar disorder (who also had had psychotic symptoms)," Michael Thase, MD, professor of psychiatry and director of the Mood Disorders Program at the University of Pennsylvania's Perelman School of Medicine, in Philadelphia, told Medscape Medical News.
The demonstration of benefit in bipolar patients is "not surprising ― the cognitive deficits are likely the result of months or years of severe mental illness (including psychosis), not the type of mental disorder. And the apparent durability of improvement after the formal intervention stopped is noteworthy," added Dr Thase, who was not involved in the study.
He also noted that the "rigor of the study is strengthened by use of a very strong control group matched for hours of computer work and credibility. In fact, the participants couldn't tell the difference between the real CR program and the sham."
Nonetheless, there are several reasons to be cautious, said Dr Thase.
"The study is relatively small, and the sample is better educated and has higher cognitive capabilities than would be seen in the general public. Worse results might be expected with a more disadvantaged group of patients," he noted. "The training program is intensive ― up to 70 hours of training was planned ― and specific improvements were not seen until the second half of the intervention period. The average participant only got about four sevenths of the planned intervention."
The significant differences observed on several cognitive measures were not associated with significant improvements in functional capacity or quality of life.
The study was supported by the National Institute of Mental Health. PositScience provided the cognitive remediation training software for research purposed free of charge but had no role in study design or data collection, analysis, interpretation, or writing of the report. Dr Lewandowski and Dr Thase have disclosed no relevant financial relationships.
J Clin Psychiatry. Published online October 17, 2017. Abstract