There is an increasing evidence of a relationship between cognitive impairment and low functioning in bipolar patients. The experience in schizophrenic patients can help to clear that neurocognitive functioning may be more strongly associated with functional outcome than clinical symptoms. In this case, and especially during the last decade, several studies have pointed out to the correlation between the performance on specific cognitive tasks and lower psychosocial functioning assessed through general measures, such as the GAF [40
]. Most of these studies tried to control for the impact of subclinical symptoms that have been considered as a negative influence for the functional recovery of bipolar patients. One of the main problems is that remission and euthymia criteria are often not clearly defined, so differences between studies were found [41
In recent studies, an association between CVLT verbal memory measures and low functioning was consistently found [3
]. Poor planning and problem solving were associated with functioning, so that difficulties with logical approaches to problems in daily living may have the greatest impact in functional outcome [44
]. Other executive function measures correlated with social disability, but weakly [45
]. TMT-B was also found to be a good correlate of functioning in bipolar I and II patients [28
]. Recent publications also reported that executive function performance was related to employment status [46
]. Moreover, a connection between the RBANS immediate memory performance and the current work status was also reported [47
Jaeger and Vieta [48
] co-edited a special issue on functionality in Bipolar Disorders, including four studies linking cognition and functioning. WCST categories correlated with GAF scores [49
]. Dittmann et al.
] reported that psychosocial functioning was significantly correlated with working memory measures. Martinez-Aran et al.
] found that CVLT verbal recall was the measure that best predicted psychosocial functioning. Finally, Jaeger et al.
] looked for predictors of functional remission one year after discharge due to an acute episode. Attention and ideational fluency were the factors that best predicted functioning. In this line, another study showed that the Neurocognitive Global Index and, specifically, speed of processing were the best predictors of functional remission at one-year follow-up [52
]. Persistent deficits in verbal memory, executive functions and attention may lead to impairments in occupational, social and interpersonal functioning, so we should optimize not only cognitive but also functional measures. There are very few longitudinal studies focused on the analysis of predictive factors of functioning in bipolar disorder. Discrepancies on the findings from different studies emphasize the need for consensus on the assessment of bipolar patients. The development of core-sets for bipolar disorder, based on the International Classification of Functioning, Disability and Health (ICF), may be useful in further research [53
]. The ISBD-BANC is promoting a consensus battery for the neurocognitive assessment of bipolar patients as well [54
]. Moreover, the use of brief instruments focused on specific functional areas affected in bipolar patients, will allow identify correlates of different areas of functioning [55
]. The cognitive measures found to be associated with functioning vary between studies and, in general, they have not been found to be strongly correlated. Findings seem to be quite consistent with regard to the relevance of verbal learning and memory measures, such as the California Verbal Learning Test on disability, using the FAST, in longer longitudinal studies [27
]. Interestingly, recent findings suggest that executive function measures may also play an essential role on functioning and disability [56
]. In this regard, Murray et al.
] have focused on specific self-management strategies used by high functioning individuals with bipolar disorder in order to maintain or regain wellness, including sleep, diet, rest and exercise, ongoing monitoring, reflective and meditative practices, understanding bipolar disorder and educating others, connecting to others and enacting a plan to prevent relapses. These findings suggest that patients receiving psychoeducation may be more likely to achieve functional recovery [58
]. A combination of psychoeducation and functional remediation may be helpful to foster recovery in these patients, taking into account that a neurodegenerative process can lead to poorer functioning in the long-term (see Fig.
Fig. (1) Functional remediation tries to cover the gap between normal functioning and low functioning associated with illness progression. Functioning probably would be higher before illness onset, and some mild difficulties would be appreciated in the prodromal (more ...)