Department of Psychiatry, University of Cambridge, Box 189, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK
We write to correct some misconceptions evident in the recent editorial by
Ferrier & Thompson (2002).
Previously, we reported impairment in accuracy measures on recognition memory
tasks and increased latencies on executive tasks in patients with bipolar
disorder in remission (Rubinsztein et
al, 2000). Ferrier & Thompson
(2002) argue that the cognitive
impairment observed in our study may have been confounded by the effects of
residual symptoms. As yet there is no generally accepted
cut-off for what constitutes remission. We devised rigorous
criteria to define remission based on a patient's own view of his or her
illness, that of their psychiatrist and a structured interview. We excluded
patients with scores of 8 on both the Hamilton Rating Scale for Depression
(HRSD) and Young Mania Scale (YMS). These rating scales were devised to rate
symptom severity in patients with an affective disorder and not for use in
normal control subjects. Our average reported score on the HRSD was 2.1
(s.e.m.=0.5) and on the YMS it was 0.8 (s.e.m.=0.4). Thus, very few residual
symptoms were evident and these scores certainly do not support any concern
that patients had residual depression or mania.
Although the rationale for using such scales in controls is dubious, for the sake of argument we have reanalysed our data reported in Rubinsztein et al (2000) using a partial correlation analysis, as in Clark et al (2002), to control for differences observed on the HRSD (we did not rate control subjects using the mania scale) on the tests that showed significant impairment by analysis of variance (ANOVA). We still find significant impairment on both the visual recognition memory tasks and on latency measures from the one-touch Tower of London planning task (see Table 1).
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These findings suggest that there are trait impairments in accuracy of visual recognition memory and slower responses on a planning task in bipolar remission. Importantly, impairments of memory and learning have been consistently observed in a number of other recent studies where rigorous diagnostic criteria for remission were applied (e.g. Van Gorp et al, 1998; Krabbendam et al, 2000; Cavanagh et al, 2002) as well as in a recent unpublished study (L. Clark, personal communication, 2002) that showed that verbal recall was still impaired following partial correlation for residual symptoms. The presence of significant impairments on executive tasks in bipolar remission has been more variable and may depend on clinical factors or the specific neuropsychological test paradigm employed. The precise functional significance of the cognitive impairment in bipolar remission needs to be examined further but may well impact on response to psychological and drug treatments. Cognitive symptoms could in fact be among the most sensitive indicators of incomplete remission.
REFERENCES
Cavanagh, J. T. O., van Beck, M., Muir, W., et al
(2002) Casecontrol study of neurocognitive function in
euthymic patients with bipolar disorder: an association with mania.
British Journal of Psychiatry,
180,
320-326.
Clark, L., Iversen, S. D. & Goodwin, G. M.
(2000) Sustained attention deficit in bipolar disorder.
British Journal of Psychiatry,
180,
313-319.
Ferrier, I. N. & Thompson, J. M. (2002)
Cognitive impairment in bipolar affective disorder: implications for the
bipolar diathesis. British Journal of Psychiatry,
180,
293-295.
Krabbendam, L., Honig, A., Wiersma, I., et al (2000) Cognitive dysfunction and white matter lesions in patients with bipolar disorder in remission. Acta Psychiatrica Scandinavica, 101, 274-280.[CrossRef][Medline]
Rubinsztein, J. S., Michael, A., Paykel, E. S., et al (2000) Cognitive impairment in remission in bipolar affective disorder. Psychological Medicine, 30, 1025-1036.[CrossRef][Medline]
Van Gorp, W. G., Altshuler, L., Theberge, D. C., et al
(1998) Cognitive impairments in euthymic bipolar patients
with and without prior alcohol dependence. Archives of General
Psychiatry, 55,
41-45.
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