Cognitive enhancement therapy for mood disorders: A new paradigm?

At a recent conference in New York City, problems with the term ‘Cognitive Remediation’ were discussed, including its assumed focus on cognitive deficit, particularly in mood disorders. Cognitive Remediation intervention trials presented at the conference often focused strongly on enhancing patient’s cognitive strengths, and thus, there was a consensus that a name change would be beneficial for this area and may translate to better understanding for clinicians and patients receiving the treatment. Concerns about the term ‘Cognitive Remediation’ may be particularly important when related to mood disorders. Cognitive Remediation for mood disorders has sometimes been conceptualised as an adaptation from Cognitive Remediation for schizophrenia. However, there are important differences related to the usual magnitude of deficits, the likely plasticity of deficits and the importance of subjective deficit which is likely to be a considerably more important factor in mood disorders. The use of the same term, ‘Cognitive Remediation’, as for the treatment in schizophrenia may therefore be problematic.

Research has now established that cognitive impairment is a core feature of mood disorders, and that impairment persists after clinical recovery has occurred. Cognitive impairment is strongly associated with day-to-day functioning, including in occupational and interpersonal areas, and thus, impacts greatly on individuals’ recovery. However, it is also recognised that many patients do not have objectively defined cognitive deficit (Douglas et al., 2018). Furthermore, it is not only objective deficit but also the subjective perception of cognitive problems which may interfere with functioning and full recovery. Despite the strength of these findings, knowledge of and motivation to address cognitive difficulties does not appear to have been translated into substantial change in clinical practice. As clinicians, we find we are often trying to motivate clinicians and therapists to recognise the importance of targeting cognitive function as part of a more comprehensive approach to enhancing overall recovery from mood disorders but are hampered by the lack of understanding of what approaches can be used.

Part of the difficulty in helping clinicians and mental health providers to understand the importance of targeting cognitive function in mood disorder recovery may be that the term ‘Cognitive Remediation’ or ‘Cognitive Rehabilitation’ has developed from separate health populations, including schizophrenia and traumatic brain injury (TBI). In TBI literature, Cognitive Remediation refers to ‘a systematically applied set of medical and therapeutic services to improve cognitive functioning’ and may involve dietary, pharmacological or surgical approaches, as well as cognitive training (Cernich et al., 2010). Rather than serving to remedy or reverse damage, as the term remediation implies, Cognitive Remediation interventions in mood disorders aim to focus on areas of weaknesses and strengths to improve cognitive and functional recovery, even in individuals who may not, objectively speaking, have observable cognitive impairment.

We therefore suggest a three pronged approach to the education of both patients and professionals regarding this problem. First, there should be continuing education regarding the importance of cognitive function and difficulties regarding this – both subjective and objective. Second, there should be an attempt to educate regarding what ‘Cognitive Remediation’ in mood disorders entails. Third, we suggest a change in the term ‘Cognitive Remediation’ for the sorts of treatments which are being proposed in mood disorders. We suggest instead the use of the term Cognitive Enhancement Therapy for Mood Disorders* or CET-MD, which we will justify below.

*We note that ‘Cognitive Enhancement Therapy’ has been used in the schizophrenia literature, and are thus using an ‘MD’ specifier to emphasise its specificity to mood disorders.

Here, we therefore include a summary of what we believe are the major components of CET-MD, the outcome of which would be to improve cognitive and functional recovery. The three main components, depicted in Figure 1, include the following: (1) psychoeducation, (2) practice and (3) translation to everyday life. The format (i.e. group vs individual and computerised vs discussion based), dose, duration and extent of therapist input will differ between programmes and between each component.

Figure 1.

Key components of cognitive enhancement therapy for mood disorders (CET-MD).

Psychoeducation

As with many other interventions, CET-MD involves discussing how and why the treatment target (in this case, cognitive function) is a worthy focus of treatment. In the case of CET-MD, this may include describing how cognitive difficulties are typical of depressive episodes, and in fact are included in major diagnostic systems used by clinicians around the world (e.g. Diagnostic and Statistical Manual of Mental Disorders, ed. 5 [DSM-5] and International Classification of Diseases, Eleventh Revision [ICD-11] each list cognitive difficulties as symptoms of depression). Beyond acute episodes, psychoeducation often describes the robust evidence that cognitive difficulties persist outside of episodes for many with mood disorders. This phase of treatment may also include assessment of an individuals’ cognitive strengths and weaknesses, their use of cognitive strategies in everyday life, and an individuals’ perceptions of their own cognitive functioning. Perceived deficits in cognitive function are a robust predictor of functional outcome (Cha et al., 2017); as such, individuals’ perceptions of their cognitive performance should be assessed as thoroughly as objective measures.

Cognitive practice

Cognitive practice involves two components: repetition with the goal of mastery of cognitive skills, and coaching and feedback on use of cognitive strategies. Repetition of tasks may also have the goal of activating brain regions thought to be underactive in depression. We find that clinicians and clients alike are often surprised to learn that Cognitive Remediation involves more than simply practicing a computerised task. Some of this misconception may stem from reports in popular media characterising computerised interventions with headlines such as ‘therapist-free therapy’ (The Economist, 2011), or from confusion about how Cognitive Remediation (now to be termed CET-MD) differs from commercially available smartphone applications that also involve cognitive practice. In CET-MD, the use of coaching and feedback about performance is essential, given the increasing recognition that deficits in motivation and effort are intrinsically linked to cognitive performance in mood disorders (Bowie et al., 2017b). Support for patients in motivating them to engage in cognitive practice and to deal with the cognitive failures which will inevitably occur during this process are also important.

Transfer to daily life

In the final component of CET-MD, cognitive skills and strategies learnt during cognitive practice are aimed to be transferred to everyday life (i.e. enhanced attention span or memory strategies). This may involve practicing work-related skills (Bowie et al., 2017a), skills for daily functioning (such as keeping a calendar), and/or discussion of how cognitive skills influence social relationships, emotion regulation strategies, or relapse prevention. Discussion of skills transfer can also include planning for how to integrate Cognitive Remediation skills alongside other intervention strategies such as cognitive restructuring or behavioural activation.

In summary, we have proposed a new term for psychological treatments for cognitive problems in mood disorders; CET-MD. This is a broad term including all psychological attempts to enhance functioning in the cognitive domain both for people with significant, objectively defined cognitive deficit and for those with subjective difficulties but which will generally contain the aforementioned components. The term acknowledges that the underlying goal is to enhance cognitive functioning, regardless of the exact nature of the underlying difficulties. It also conceptualises the domain of cognitive function as an area which can be enhanced in many people with mood disorders and which is always worthy of consideration in mood disorders. It leads to the question in each individual patient ‘how can cognitive function be enhanced?’ – something which should be assessed and addressed in all patients with mood disorders (as are other domains such as sleep or circadian rhythm). We suggest that all readers of this paper begin to consider this question and to introduce this into their clinical practice.