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Archives of Clinical Psychiatry (São Paulo)

versão impressa ISSN 0101-6083versão On-line ISSN 1806-938X

Arch. Clin. Psychiatry (São Paulo) vol.45 no.5 São Paulo set./out. 2018 

Letter to the Editor

The meaning of cognitive dysfunction in bipolar disorder: a risk factor or a specific form of dementia?

Cássio Silveira de Jesús1 

Marlos Vasconcelos Rocha1 

Ângela Miranda-Scippa1  2 

1Program of Mood and Anxiety Disorders (CETHA), University Hospital, Federal University of Bahia, Salvador, BA, Brazil.

2Postgraduate Program in Medicine and Health, Federal University of Bahia, Salvador, BA, Brazil. Department of Neurosciences and Mental Health, Medical School, Federal University of Bahia, Salvador, BA, Brazil.

Dear Editor,

Bipolar disorder (BD) is a chronic pathology with a worldwide prevalence of 2.4% in its classic presentations1. Studies show that the depressive, mania/hypomania crises are neurotoxic and cognitive impairment is present both in the acute phases as well as in euthymia. However, bipolar type I patients have more cognitive changes than type II patients, most likely due to greater toxicity of manic episodes, with greater release of inflammatory cytokines, reduction of brain-derived neurotrophic factor (BDNF), higher oxidative stress and, consequently, loss of neuroprotective mechanisms2. In this sense, more than the time of disease duration, the number of manic episodes seems to determine the exacerbation of cognitive decline, mainly in patients presenting psychotic symptoms2,3.

In BD patients, cognitive deficits are found in several domains, such as processing speed, visuospatial abilities, verbal memory and attention, with the last two being the most impaired3. Furthermore, evidence shows that these deficits are associated with total brain atrophy, enlargement of the lateral ventricles, decrease of the corpus callosum volume, and the reduction of the hippocampus, findings that are also found in neurodegenerative diseases such as dementia4,5. Besides that, according to the theory of neuroprogression in BD stage 4, there are loss of autonomy due to cognitive and functional impairment, associated with enlargement ventricle and/or white matter hyperintensities, increase of tumor necrosis factor α (TNF-α), increase of nitrotyrosine 3, decrease of BDNF, increase of interleukins 6, 10, and glutathione transferase4.

So, although several studies point to BD as a risk factor for dementia, we question whether the cognitive dysfunctions present in some of these patients are not enough to affirm that there also a “bipolar dementia”, just like it's done in other pathologies such as Parkinson's disease6 and epilepsy7. In fact, Parkinson's disease, epilepsy and BD patients who develop cognitive dysfunction do not present the changes in the cerebrospinal fluid as are described in Alzheimer's disease, such as low concentrations of beta amyloid protein and high concentrations of total and phosphorylated tau protein5. In BD, like in these diseases, there is cognitive impairment; the deficits emerge over time with the recurrence of crises and there is no evidence pointing to a related or altered specific substance, leading to neurodegeneration3.

Recognizing BD as a pathology that might cause a subtype of dementia is important to reinforce the need for adequate diagnosis and treatment, bearing in mind the loss of functionality of the patients who present cognitive deficits. Furthermore, we should remember that BD has a high comorbidity with metabolic syndrome, which may also contribute toward microangiopathy and vascular dementia scenarios, whose physiopathology is different from dementia due to neurodegeneration. Thus, we pose the following question: is BD only a risk factor for dementia or must be considerate a distinct clinical entity?


The authors report no conflicts of interest.


1. Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld RMA, Petukhova M, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the national comorbidity survey replication. Arch Gen Psychiatry. 2007;64(5):543-52. [ Links ]

2. Piccinni A, Marazziti D, Callari A, Franceschini C, Veltri A, Bartolommei N, et al. Bipolar disorder and dementia: a close link. Clin Neuropsychiatry. 2015;12(2):27-36. [ Links ]

3. Cardoso T, Bauer IE, Meyer TD, Kapczinski F, Soares JC. Neuroprogression and cognitive functioning in bipolar disorder: a systematic review. Curr Psychiatry Rep. 2015;17(9). [ Links ]

4. Roda A, Chendo I, Kunz M. Biomarkers and staging of bipolar disorder: a systematic review. Trends Psychiatry Psychother. 2015;37(1):3-11. [ Links ]

5. Forlenza OV, Aprahamian I, Radanovic M, Talib LL, Camargo MZA, Stella F, et al. Cognitive impairment in late-life bipolar disorder is not associated with Alzheimer's disease pathological signature in the cerebrospinal fluid. Bipolar Disord. 2016;18(1):63-70. [ Links ]

6. Hanagasi HA, Tufekcioglu Z, Emre M. Dementia in Parkinson's disease. J Neurol Sci. 2017;374(2016):26-31. [ Links ]

7. Breuer LEM, Grevers E, Boon P, Bernas A, Bergmans JWM, Besseling RMH, et al. Cognitive deterioration in adult epilepsy: clinical characteristics of “Accelerated Cognitive Ageing.” Acta Neurol Scand. 2017;136(1):47-53. [ Links ]

Received: July 25, 2018; Accepted: August 08, 2018

Address for correspondence: Cássio Silveira de Jesús. University Hospital, Federal University of Bahia. Rua Dr. Augusto Viana, s/n, Canela - 40110-060 - Salvador, BA, Brazil. Email:

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