An updated review on the neuropsychological profile of subjects with bipolar disorder

Szmulewicz, Alejandro G.; Samamé, Cecilia; Martino, Diego J.; Strejilevich, Sergio A.

doi:10.1590/0101-60830000000064

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Review articles • Arch. Clin. Psychiatry (São Paulo) 42 (5) • Sep-Oct 2015 • https://doi.org/10.1590/0101-60830000000064 linkcopy

An updated review on the neuropsychological profile of subjects with bipolar disorder

Authorship SCIMAGO INSTITUTIONS RANKINGS

Background In recent years, growing interest in the neuropsychology of bipolar disorder has emerged, giving rise to the accumulation of a robust body of evidence on this topic and to several related questions.

Objective To provide a state-of-the-art overview of the neuropsychological profile of bipolar disorder.

Method A thorough literature search was performed. Published research evidence was summarized and organized along three key pathways: findings from cross-sectional studies of cognition in bipolar patients, cognitive heterogeneity among affected subjects, and trajectory of neuropsychological deficits.

Results At least two thirds of bipolar patients display neuropsychological deficits, even in euthymia. Although bipolar disorder was found to be associated with an increased risk of dementia, data from elderly subjects and longitudinal research do not support a worsening of cognitive performance over time.

Discussion Cognitive dysfunctions are part of the clinical conceptualization of bipolar illness. However, they may not be present in all affected subjects and their course appears to be stable in most cases. Available evidence may be highlighting the fact that bipolar disorder is characterized by remarkable heterogeneity regarding cognitive outcomes. Different variables may be related to such heterogeneity and should be the focus of therapeutic approaches and further research.

Bipolar disorder; neuropsychological functioning; heterogeneity; evolution

Meta- analysis	Study population	Mood state	Results^a
Arts et al. (2008)²²	Adult patients and FDR	Euthymia	BD: Large effect sizes for executive functions and verbal memory Medium effect sizes for processing speed and sustained attention Small effect sizes for visuoperception FDR: small, but significant, effect sizes across cognitive domains
Bora et al. (2009)²³	Adult patients and FDR	Euthymia	BD: Moderate-to-large effect sizes for executive functions, sustained attention and verbal memory FDR: small, but significant, effect sizes across cognitive domains
Bora et al. (2011)²⁴	Adult patients	Euthymia and depression (mixed sample)	Small-to-moderate effect sizes across all domains (BD II-only vs. controls) BD II less impaired than BD I on memory measures
Bora and Pantelis (2015)⁴⁹	FEBD	Euthymia and mood episodes (mixed sample)	Moderate effect sizes for attention, processing speed, verbal and visual memory. Small effect sizes for most executive domains
Bourne et al. (2013)²⁷	Adult patients	Euthymia	Small-to-moderate effect sizes for verbal memory, executive functions and sustained attention
Garcia Nieto and Castellanos (2011)¹⁸	Pediatric patients	Euthymia and mood episodes (mixed sample)	Moderate effect sizes for verbal memory, attention, processing speed and executive domains
Joseph et al. (2008)¹⁷	Pediatric patients	Euthymia and mood episodes (mixed sample)	Moderate-to-large effects for verbal memory, attention, executive functions, working memory and verbal fluency. Small effects for IQ and motor speed
Kurtz and Gerraty (2009)²⁵	Adult patients	Euthymia Manic episode Depressive episode	Euthymia: moderate effect sizes for attention, delayed memory and executive functions. Large effect sizes for verbal learning Depressive and manic episodes: more severe impairment in verbal learning and phonemic fluency
Lee et al. (2014)⁴⁸	FEBD	Euthymia and manic episode	Medium-to-large deficits for psychomotor speed, attention, working memory and cognitive flexibility Small deficits for verbal learning and memory, attentional switching, and verbal fluency. Medium-to-large deficit for response inhibition only detected in non-euthymic cases
Mann-Wrobel et al. (2011)²⁶	Adult patients	Euthymia	Moderate-to-large effect sizes across all domains
Robinson et al. (2006)²⁰	Adult patients	Euthymia	Large effect sizes for executive function and verbal learning. Medium effect sizes for delayed recall, set-shifting, processing speed, sustained attention and response inhibition. Small effect sizes for verbal fluency
Torres et al. (2007)²¹	Adult patients	Euthymia	Medium-to-large impairment for executive functions, attention, processing speed and episodic memory
Trotta et al (2015)¹²	Subjects in the premorbid stage of illness	Euthymia	Non-significant overall effect size for IQ between subjects who subsequently developed BD and those who did not develop any disorder
Samamé et al. (2012)³⁰	Adult patients	Euthymia	Non-significant overall effect size for decision-making (Iowa Gambling Task). Small effect size for facial emotion recognition. Moderate effect sizes for mentalizing domains
Samamé et al. (2013)³³	Elderly patients	Euthymia	Non-significant differences for the MMSE and CDT. Moderate effect sizes for sustained attention, digit span, delayed recall, verbal fluency and cognitive flexibility
Samamé et al. (2015)²⁹	Adult patients	Euthymia	Medium effect size for the Faux-Pas test. Non-significant differences for the recognition of three emotions (happiness, anger and sadness). Small effect size for the recognition of surprise, fear and disgust, emotional intelligence and the Hinting task

Methodological approach	Results	Main limitations
Cognitive functioning in first-episode BD	Inconsistent findings. Both impaired and preserved cognitive outcomes have been reported^48-50	Small sample sizes Results potentially confounded by mood symptomatology
Longitudinal research	Longitudinal meta-analysis does not show any test-retest differences for neurocognitive variables⁵¹	Short follow-up periods Few data on healthy controls Dropout bias Results potentially confounded by mood symptomatology Results only account for the course of cognitive deficits after illness onset
Cognitive functioning in long-standing BD	Meta-analysis of cognition in E-BD subjects shows a pattern and magnitude of impairment similar to those reported for young adult patients³³ Comparison between Y-BD and E-BD reveals no significant differences in cognitive performance⁵⁵	Small sample sizes Few studies performed on E-BD BD patients with poor outcomes (dementia, institutionalized) probably not included in E-BD samples
Population-based studies	An association between BD and an increased risk of dementia is supported by available data^58,59	These studies reflect the outcome of a minority of BD patients (6%-9%)

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[TFN1] ^a All effect sizes favor healthy controls.

[TFN2] BD: bipolar disorder; FDR: first degree relatives; FEBD: first episode bipolar disorder; MMSE: Mini-Mental State Examination; CDT: Clock Drawing Test.