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Is Cognitive Remediation Therapy effective in improving thinking skills and everyday functioning in Bipolar Disorder?

by Ailbhe Madigan BA MSc, Research Assistant at King’s College London
A person holds a large scribbled brain connected by a line to a silhouette with a tangled brain. Blue background, concept of communication.

As innovative mental health interventions continue to emerge, evaluating their feasibility and acceptability is essential for improving patient outcomes. A recent study conducted by King’s College London and funded by the NIHR Research for Patient Benefit Program and the NIHR Maudsley Biomedical Research Centre (1) examined the value of delivering Cognitive Remediation Therapy (CRT) to people with Bipolar Disorder.


Two-thirds of people with Bipolar Disorder experience wide-ranging and long-lasting cognitive difficulties, such as problems with memory, attention and planning, that affect their daily lives and functioning (2). These cognitive problems can increase the chance of further episodes, so enhancing thinking skills may improve both short- and longer-term wellbeing (3).


Research studies have shown that cognitive remediation - a psychological intervention that aims to improve everyday functioning by targeting thinking skills - benefits those with schizophrenia, improving both their thinking skills and quality of life (4). Since people with Bipolar Disorder often experience cognitive difficulties similar to those with schizophrenia (5), the CRiB study set out to explore whether this intervention can help them too.


The study investigated whether the individual, therapist-led CIRCuiTS™ programme for adults with Bipolar Disorder is:

  1. Feasible

  2. Acceptable

  3. Beneficial for cognitive performance

  4. Effective in improving psychosocial functioning (the ability to interact and relate to others, work, and engage in social activities)


Sixty participants with Bipolar Disorder were randomly assigned to either CRT using the CIRCuiTS™ programme or treatment as usual (TAU). The results suggest that individual, therapist-led CRT using CIRCuiTS™ is highly feasible and acceptable for people with Bipolar Disorder and may enhance their thinking skills and daily life functioning. Despite the relatively small sample size (60 people in total), large effects on cognition and achievement of personal goals were observed up to three months post-treatment. These effects are larger than those from previous trials of CRT in people with schizophrenia and Bipolar Disorder.


This trial had several strengths: it was preregistered, included independent randomisation, and had minimal missing data. However, because it was a feasibility study, it is difficult to draw firm conclusions about clinical benefits. The sample was too small to identify other factors that might influence outcomes, like medications, physical illness and sleep quality. Moreover, the participants were predominantly white, British and educated, so it is difficult to generalise the findings to the wider bipolar community.


While medications are commonly used to target mood in people with Bipolar Disorder, we also know that these individuals seek additional psychological therapies that can help to improve their quality of life more broadly (6). CRT (using CIRCuiTS™) may be a promising candidate to meet those needs, and this study highlights that the intervention is both acceptable and feasible for service users. A larger-scale study - CRiB2 - is now underway, building on these encouraging results. As this second study will involve 250 participants from more diverse backgrounds, it will allow us to understand more about the personal factors that help or hinder treatment benefits (7).



More information about the ongoing CRIB2 study can be found here:


References

(1)   Strawbridge, R., Tsapekos, D., Hodsoll, J., Mantingh, T., Yalin, N., McCrone, P., Boadu, J., Macritchie, K., Cella, M., Reeder, C., Fish, J., Wykes, T., & Young, A. H. (2020). Cognitive remediation therapy for patients with bipolar disorder: A randomised proof‐of‐concept trial. Bipolar Disorders, 23(2), 196–208. https://doi.org/10.1111/bdi.12968


(2)   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/s0033291714000439


(3)   Tsapekos, D., Seccomandi, B., Mantingh, T., Cella, M., Wykes, T., & Young, A. H. (2019). Cognitive enhancement interventions for people with bipolar disorder: A systematic review of methodological quality, treatment approaches, and outcomes. Bipolar Disorders, 22(3), 216–230. https://doi.org/10.1111/bdi.12848


(4)   Reeder, C., Huddy, V., Cella, M., Taylor, R., Greenwood, K., Landau, S., & Wykes, T. (2017). A new generation computerised metacognitive cognitive remediation programme for schizophrenia (CIRCuiTS): a randomised controlled trial. Psychological Medicine, 47(15), 2720–2730. https://doi.org/10.1017/s0033291717001234


(5)   Trotta, A., Murray, R. M., & MacCabe, J. H. (2014). Do premorbid and post-onset cognitive functioning differ between schizophrenia and bipolar disorder? A systematic review and meta-analysis. Psychological Medicine, 45(2), 381–394. https://doi.org/10.1017/s0033291714001512


(6)   Nestsiarovich, A., Hurwitz, N. G., Nelson, S. J., Crisanti, A. S., Kerner, B., Kuntz, M. J., Smith, A. N., Volesky, E., Schroeter, Q. L., DeShaw, J. L., Young, S. S., Obenchain, R. L., Krall, R. L., Jordan, K., Fawcett, J., Tohen, M., Perkins, D. J., & Lambert, C. G. (2017). Systemic challenges in bipolar disorder management: A patient-centered approach. Bipolar Disorders, 19(8), 676–688. https://doi.org/10.1111/bdi.12547


(7)   Tsapekos, D., Strawbridge, R., Cella, M., Goldsmith, K., Kalfas, M., Taylor, R. H., ... & Young, A. H. (2023). Cognitive Remediation in Bipolar (CRiB2): study protocol for a randomised controlled trial assessing efficacy and mechanisms of cognitive remediation therapy compared to treatment as usual. BMC psychiatry, 23(1), 842.

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