Identifying and treating cognitive impairment in bipolar disorder

Objectives:  The presence of cognitive deficits has become increasingly appreciated across all phases of bipolar disorder. The present review sought to identify domains of cognitive dysfunction, methods of assessment, discrimination of iatrogenic from illness‐specific etiologies, and pharmacologic strategies to manage cognitive problems in patients with bipolar disorder. Methods:  A selective literature review was performed focusing on studies of descriptive phenomenology and pharmacologic intervention (favoring randomized comparisons when existent but open trials or case reports when not) involving cognition in bipolar disorder populations, healthy volunteers, or other clinical populations. Identification was made of (i) practical strategies for clinical assessment and management of cognitive complaints, (ii) limitations of existing intervention studies, and (iii) recommendations for the design and direction of future research. Results:  Cognitive deficits involving attention, executive function, and verbal memory are evident across all phases of bipolar disorder. Most existing treatment studies involve nonbipolar populations, prompting caution when extrapolating outcomes to individuals with bipolar disorder. Differentiating medication‐ from illness‐induced cognitive dysfunction requires comprehensive assessment with an appreciation for the cognitive domains most affected by specific medications. No current pharmacotherapies substantially improve cognition in bipolar disorder, although preliminary findings suggest some potential value for adjunctive stimulants such as modafinil and novel experimental agents. Conclusions:  Circumscribed cognitive deficits may be both iatrogenic and intrinsic to bipolar disorder. Optimal management hinges on a knowledge of illness‐specific cognitive domains as well as of the beneficial or adverse cognitive profiles of common psychotropic medications.