Beruflich Dokumente
Kultur Dokumente
discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/236052231
CITATIONS
READS
12
162
13 authors, including:
Jose Snchez-Moreno
Brisa Sole
SEE PROFILE
SEE PROFILE
Iria Grande
Dina Popovic
SEE PROFILE
SEE PROFILE
Research report
Bipolar Disorders Program, Institute of Neurosciences, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM. Villarroel 170, Barcelona,
08036 Catalonia, Spain
b
Bipolar Disorders Program & INCT for Translational Medicine, Hospital de Clnicas de Porto Alegre, Universidade Federal do Rio Grande do Sul,
Ramiro Barcelos 2350, Porto Alegre, Rio Grande do Sul 90035903, Brazil
c
Department of Child and Adolescent Psychiatry and Psychology, Institut Clnic of Neurosciences, Hospital Clnic Universitari, Barcelona Villarroel, 170,
Barcelona 08036, Spain
d
Clinical Psychology. Department, Institute of Neurosciences, Hospital Clinic, IDIBAPS, University of Barcelona. Villarroel 170, Barcelona 08036, Spain
e
rio Unilasalle Rua Victor Barreto 2288, Canoas, RS, Brasil
Centro Universita
a r t i c l e i n f o
abstract
Article history:
Received 23 October 2012
Received in revised form
7 February 2013
Accepted 7 February 2013
Available online 14 March 2013
Background: Discrepancies between bipolar patients reports and neuropsychological testing have been
described and replicated. Unfortunately, no valid, specic, user-friendly, brief instrument is available to
measure cognitive decits as reported by these patients. The main aim of this study was to validate a
novel instrument named the cognitive complaints in bipolar disorder rating assessment (COBRA).
Second, we investigated the relationship between the COBRA, objective cognitive measures and illness
course variables.
Method: The total sample (N 215) included 91 bipolar disorder patients and 124 healthy controls. The
psychometric properties of the COBRA (e.g. internal consistency, concurrent validity, discriminative
validity, factorial analyses, ROC curve and feasibility) were analyzed. A complete neuropsychological
battery was used as objective cognitive assessment.
Results: The COBRA had one-factor structure with very high internal consistency (Cronbachs
alpha 0.913). A high convergent validity was indicated by a strong correlation with the Frankfurt
Complaint Questionnaire (ro 0.888, p o 0.001). Bipolar patients experienced greater cognitive complaints compared to control group suggesting a discriminative validity of the instrument. Signicant
correlations were found between the COBRA and some objective cognitive measures. Furthermore,
higher COBRA scores were associated with bipolar II subtype, residual depressive symptoms,
hypomanic episodes and total episodes.
Limitations: The cross-sectional design of the study, the inuence of medication and severity of patients
included.
Conclusions: The COBRA showed to be a useful instrument to assess overall cognitive complaints in
bipolar disorder with very satisfactory psychometric properties. Cognitive complaints were partially
correlated with memory and executive function measures and with issues that may increase the
subjective perception of cognitive decits, such as subthreshold depressive symptoms and number of
episodes.
& 2013 Elsevier B.V. All rights reserved.
Keywords:
Cognitive complaints
Cognitive impairment
Bipolar disorder
1. Introduction
Evidence has shown that patients with bipolar disorder experience
cognitive impairment both during acute episodes and remission
periods (Martinez-Aran et al., 2004; Robinson et al., 2006). In
0165-0327/$ - see front matter & 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.jad.2013.02.022
30
disorders (Svendsen et al., 2012). In addition, a complete neurocognitive battery requires a longer time to administrate besides high
costs, which may limit its use, especially in the clinical practice.
Other available instruments, such as the Mini Mental State Examination (MMSE), commonly used in medicine to screen for dementia, are too basic to assess cognitive decits in psychiatric patients,
especially in young people. This instrument is not suitable to detect
cognitive impairment in patients with bipolar disorder with a
medium-high intellectual level. For this reason, the development
of brief instruments to assess cognitive decits reported by patients
is needed, especially in order to establish the relationship between
subjective cognitive complaints and objective cognitive decits. The
16-item Cognitive complaints in bipolar disorder rating assessment
(COBRA) is a self-reported instrument which allows us to assess
cognitive dysfunctions regarding the main decits experienced by
bipolar patients and reported in the literature. A better understanding about cognitive function could help clinicians to implement a more individualized treatment for bipolar patients.
Moreover, the validity of the subjective cognitive measures in
bipolar disorder is an important issue (Arts et al., 2011; Burdick
et al., 2005; Martinez-Aran et al., 2005). In this sense, most studies
have shown a relatively weak association between subjective
cognitive measures and neuropsychological test (Burdick et al.,
2005; Svendsen et al., 2012; van der Werf-Eldering et al., 2011).
Furthermore, subjective cognitive measures seem to be correlated
with depressive symptoms, suggesting that such measures may
reect depression severity rather than core cognitive impairment
(Svendsen et al., 2012; van der Werf-Eldering et al., 2011). The main
aim of the current study is to examine the psychometric properties
(including internal consistency, concurrent validity, discriminative
validity, factorial analyses, ROC curve and feasibility) of the COBRA.
We also investigate to what extent there is a relationship between
the COBRA, objective cognitive measures (assessed by neuropsychological battery) and the course of the illness.
2. Methods
2.1. Subjects
A total of 215 subjects participated in the study. We included 91
patients (age 1766 years) with DSM-IV bipolar I (n70, 76.92%)
and bipolar II (n21, 23.08%) and meeting criteria of remission
dened as a score r8 on the 17-Hamilton Depression Rating Scale
(HAM-D; (Bobes et al., 2003; Hamilton, 1960) and on the Young
Mania Rating Scale (YMRS; (Colom et al., 2002; Young et al., 1978)
for at least three months previous to the assessment. All patients
were enrolled in the Bipolar Disorders Program at the Hospital
Clinic of Barcelona, Spain (Vieta, 2011a).
One hundred twenty four volunteers who did not meet criteria
for any psychiatric disorder (according to the DSM-IV) were
included as healthy controls. We also made sure that controls
had no rst-degree relatives with bipolar disorder or other
psychiatric disorders. The healthy comparison group was
recruited from the general population within the catchment area
of the Hospital Clinic of Barcelona.
This study was approved by the Ethics Committee of the
Hospital Clinic of Barcelona. After a complete verbal description
of the study, all participants had written informed consent.
2.2. Assessments
(First et al., 1997). Socio-demographic, clinical and pharmacological data were collected via a structured interview with the
patient and by examination of clinical records. The 17-HAM-D
and the YMRS were administered to assess depressive and
manic symptoms, respectively.
Subjective cognitive measures
(a) The COBRA was developed by the Bipolar Disorder Program
at the Hospital Clinic of Barcelona (Vieta, 2011b) in order to
detect the main daily cognitive complaints experienced by
bipolar patients. The initial version was built and tested in a
pilot study with bipolar patients and healthy controls
(unpublished). The nal version of the COBRA is a 16-item
self-reported instrument, which allows measure subjective
cognitive dysfunctions including executive function, processing speed, working memory, verbal learning and memory,
attention/concentration and mental tracking. All of items are
rated using a 4-point scale, 0never, 1sometimes,
2often, and 3 always (see Spanish and English versions
in Appendix 1). The COBRA total score is obtained when the
scores of each item are added up. The higher the score, the
more subjective complaints.
The linguistic adaptation of the COBRA started with a
document in English obtained by a translation/backtranslation method. The items not resulting in an appropriate wording equivalence with the original text were
analyzed by the team of investigators and the translators
until they agreed upon an appropriate expression. Subsequently, bilingual people evaluated the degree of equivalence between the Spanish original and the English version.
(b) The Frankfurt Complaint Questionnaire, which is an
unspecic but reliable instrument to assess cognitive
difculties in mental disorders, was also used to assess
subjective cognitive difculties (Cuesta et al., 1996).
Validity and reliability assessment
a) Internal consistency reliability of the COBRA was assessed
by the Cronbachs coefcient a.
b) Concurrent validity for the COBRA was assessed in three ways:
(1) to examine the relationship between the COBRA and
Frankfurt Complaint Questionnaire; (2) to investigate the
association between the COBRA and objective cognitive measures (neuropsychological battery); (3) to investigate the possible correlations between the COBRA and course of the illness.
c) Validity as a discriminative measure to detect differences
between bipolar patients and healthy controls was analysed by non-parametric test.
d) The optimal point for the COBRA was determined by means
of ROC curve.
e) An exploratory factorial analysis by Principal Axis Factoring
method (Quartimax with Kaiser normalization) was performed to describe the internal structure of the COBRA.
f) Feasibility was described as the percentage of patients and
controls who did respond to the questionnaire in its entirety.
Objective cognitive measures
a) Estimated premorbid IQ. This measure was estimated with
the WAIS-III vocabulary subtest (Weschler, 1997b).
b) Processing speed. It consisted on the two subtest of the
WAIS-III to estimate the processing-speed index: Digitsymbol coding and symbol search (Weschler, 1997b).
c) Executive function. This domain included tests of set
shifting, verbal uency, planning and response inhibition:
3. Results
The mean age of the patients was 41.83711.28 years and mean
age of the controls was 39.40711.59 years; p0.129). Fortyeight
(53.9%) patients and 62 (50%) of controls were men (p0.581).
Amongst the bipolar group, mood stabilizers were the most
31
Table 1
Clinical and sociodemographic characteristics of the sample.
Age
Age at onset
Number of hospitalizations
Number of hypomanic episodes
Number of manic episodes
Number of depressive episodes
Number of mixed episodes
Number of total episodes
Number of suicidal attempts
Gender, male
University or post-graduate completed
Married
Current employed
Living alone
Depressive onset
Lifetime history of psychotic symptoms
Family history of affective disorders
Lifetime substance abuse
Life events
Rapid cycling
Seasonal pattern
Axis I comorbidity
Axis II comorbidity
Axis III comorbidity
t student
41.83
31.38
1.68
3.52
2.42
6.13
0.78
12.33
0.71
(11.28)
(10.68)
(1.95)
(4.82)
(2.61)
(7.32)
(1.59)
(10.89)
(1.26)
39.4 (11.59)
0.053
0.129
(53.9)
(53.9)
(34.1)
(52.2)
(16.1)
(53.3)
(69.3)
(64.8)
(33.3)
(77.1)
(18.3)
(35.4)
(25)
(9.2)
(60.7)
62 (50)
0.321
0.581
48
48
31
47
14
48
61
57
28
64
15
29
22
8
51
32
Fig. 1. Concurrent validity of the COBRA. A Spearman correlation between COBRA and Frankfurt Complaints Questionnaire scores (ro 0.888, p o0.001).
Table 2
Associations between subjective and objective cognitive measures in both groups.
Estimated premorbid IQ
Patients COBRA
ro (p)
Controls COBRA
ro (p)
0.150 (0.225)
0.101 (0.622)
0.278 (0.026)
0.067 (0.747)
Executive functions
WCST
Perseverative errors
SCWT
Interference PD
TMT
Trail B
Rey gure planning
0.081 (0.806)
0.141 (0.493)
0.239 (0.058)
0.222 (0.067)
0.247 (0.225)
0.202 (0.104)
0.287 (0.155)
0.437 (0.0001)
0.170 (0.173)
0.251
0.159
0.185
0.241
0.261
(0.042)
(0.199)
(0.134)
(0.050)
(0.033)
0.327 (0.006)
0.204 (0.318)
0.258 (0.203)
0.349
0.234
0.086
0.079
0.02
(0.080)
(0.251)
(0.277)
(0.700)
(0.993)
0.029 (0.887)
Table 3
The value of Spearmans correlation coefcients between COBRA and course of
bipolar disorder.
COBRA total score (n 91), ro (p)
Age
Age at onset
Number of hospitalizations
Number of hypomanic episodes
Number of manic episodes
Number of depressive episodes
Number of mixed episodes
Number of total episodes
Number of suicidal attempts
17-HAM-D
YMRS
0.175
0.035
0.079
0.267
0.180
0.204
0.194
0.240
0.069
0.297
0.028
(0.104)
(0.744)
(0.457)
(0.015)
(0.091)
(0.058)
(0.079)
(0.024)
(0.558)
(0.006)
(0.796)
33
Fig. 2. ROC curve between patients and controls. The area under the curve was 0.748. 95% CI: (0.6790.816). The cut-off point 10 indicates the best balance between
sensitivity (68.1%) and specicity (68.5%).
4. Discussion
Table 4
Factorial loading on the COBRA.
Factor
1
Item
Item
Item
Item
Item
Item
Item
Item
Item
Item
Item
Item
Item
Item
Item
Item
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
0.781
0.775
0.767
0.72
0.679
0.675
0.661
0.658
0.642
0.585
0.58
0.524
0.519
0.504
0.5
0.478
0.514
0.472
3.8. Feasibility
Finally, the results showed a high feasibility of the COBRA
since that the totality of participants answered all items of the
instrument.
34
2012; Svendsen et al., 2012; van der Werf-Eldering et al., 2011). Using
a multiple regression analysis, depressive severity was identied as a
potential predictor for subjective cognitive dysfunction, assessed by
the Massachusetts General Hospital Cognitive and Physical Functioning Questionnaire (CPFQ), in a bipolar sample (Svendsen et al., 2012).
Another independent study showed that higher CPFQ total score was
signicantly correlated with mood symptoms (depression and manic)
as well as with anxiety (Miskowiak et al., 2012). Although emerging
data suggest that neuropsychological decits are an inherent feature
of bipolar disorder given that it occurs across mood states (MartinezAran et al., 2004;Torrent et al., 2007), a recent research found that
patients with subthreshold depressive symptoms are more impaired
in verbal learning than asymptomatic patients, using more restrictive
euthymia criteria (Bonnin et al., 2012), although no other differences
were found between group with respect to the remaining cognitive
measures. Anyway, these ndings highlight the potential negative
impact of subclinical depressive symptoms on objective but more
specically on subjective cognitive dysfunctions. An explanation may
have to do with the fact that depressed patients tend to underestimate their capacities and overestimate their decits.
The current study has some limitations. First, all patients were
recruited from a tertiary hospital where participants tend to present
more severe symptoms, and may not be readily generalized to the
wider population of subjects with bipolar disorder. Second, since our
patients were on pharmacological treatment, we cannot discount the
effects of drugs on objective and subjective cognitive measures.
Medication is likely to have an impact on subjective and objective
cognitive performance (Torrent et al., 2011; Videira et al., 2012). Some
psychometric properties such as testretest reliability and sensitive to
change of the COBRA were not performed, which should be investigated in follow-up studies. We should further analyze whether
subjective cognitive complaints may predict cognitive performance
in the long term (Arts et al., 2011). And despite our strict denition of
euthymia, cognitive complaints should be assessed when the patient
is in full remission, because subclinical symptoms may increase the
risk of experiencing subjective cognitive difculties. Psychoeducation
about cognitive decits and the potential role of clinical and pharmacological factors on cognition could be helpful to address this
common problem reported by patients in clinical practice.
In conclusion, the COBRA is a brief 16-item, self-reported instrument, which allows us to investigate cognitive dysfunctions focusing
on executive function, processing speed, working memory, verbal
learning and memory, attention/concentration and mental tracking
which are the main cognitive decits experienced by bipolar patients.
The instrument discriminates cognitive function between patients
and controls showing that a cut-off point higher 10 supports the
presence of cognitive impairment. Subjective cognitive measures
were partially correlated with some objective cognitive assessment
(e.g. executive function and memory tasks) and with poor course of
bipolar illness. Even though self-reports may be somehow biased, we
should take into consideration the patients view of cognitive problems through an instrument specically addressed to the difculties
commonly reported by bipolar patients in both clinical practice and
investigation. Subjective cognitive complaints do not always correspond to objective cognitive impairment. However, a neuropsychological battery, performed by a neuropsychologist, is required to
conrm cognitive decits. A longitudinal study including both objective and subjective assessments, as measured with the COBRA, may
greatly contribute to the knowledge about the clinical relevance and
outcome of cognitive complaints in bipolar disorder.
Author disclosure
Dr. Martinez-Aran has served as speaker or advisor for the
following companies: Bristol Myers-Squibb, Otsuka, Pzer, research
funding from the Spanish Ministry of Science and Innovation.
Nunca
A veces
Frecuentemente
Siempre
35
Never
Sometimes
Often
Always
References
Arts, B., Jabben, N., Krabbendam, L., van, O.J., 2011. A 2-year naturalistic study on
cognitive functioning in bipolar disorder. Acta Psychiatrica Scandinavica 123
(3), 190205.
Benton,A.L., Hamsher,K., 1976. Multilingual Aphasia Examination. University of
Iowa, Iowa City.
Bobes, J., Bulbena, A., Luque, A., Dal, Re,R., Ballesteros, J., Ibarra, N., 2003. A
comparative psychometric study of the Spanish versions with 6, 17, and 21
items of the Hamilton Depression Rating Scale. Medicina Clininica (Barcelona)
120 (18), 693700.
Bonnin, C.M., Martinez-Aran, A., Torrent, C., Pacchiarotti, I., Rosa, A.R., Franco, C.,
Murru, A., Sanchez-Moreno, J., Vieta, E., 2010. Clinical and neurocognitive
predictors of functional outcome in bipolar euthymic patients: a long-term,
follow-up study. Journal of Affective Disorders 121 (1-2), 156160.
Bonnin, C.M., Sanchez-Moreno, J., Martinez-Aran, A., Sole, B., Reinares, M.,
Rosa, A.R., Goikolea, J.M., Benabarre, A., yuso-Mateos, J.L., Ferrer, M., Vieta, E.,
Torrent, C., 2012. Subthreshold symptoms in bipolar disorder: impact on
neurocognition, quality of life and disability. Journal of Affective Disorders 136
(3), 650659.
Burdick, K.E., Endick, C.J., Goldberg, J.F., 2005. Assessing cognitive decits in
bipolar disorder: are self-reports valid? Psychiatry Research.
Colom, F., Vieta, E., Martinez-Aran, A., Garcia-Garcia, M., Reinares, M., Torrent, C.,
Goikolea, J.M., Banus, S., Salamero, M., 2002. Spanish version of a scale for the
assessment of mania: validity and reliability of the Young Mania Rating Scale.
Medicina Clininica (Barcelona) 119 (10), 366371.
Cuesta, M.J., Peralta, V., Irigoyen, I., 1996. Factor analysis of the Frankfurt
Complaint Questionnaire in a Spanish sample. Psychopathology 29 (1), 4653.
Delis, D.C., Kramer, J.H., Kaplan, E., Ober, B., 1987. California Verbal Learning Test.
Psychological Corporation, New York.
First, M.B., Spitzer, R., Gibbon, M., 1997. Structured Clinical Interview for DSM IV
Axis I Disorder, Research Version. NewYork Biometrics Research.
Fuentes-Dura, I., Balanza-Martinez, V., Ruiz-Ruiz, JC., Martinez-Aran, A., Giron, M.,
Sole, B., Sanchez-Moreno, J., Gomez-Beneyto, M., Vieta, E., Tabares-Seisdedos, R.,
2012. Neurocognitive training in patients with bipolar disorders: current status
and perspectives. Psychotherapy and Psychosomatics 81 (4), 250252.
Goldberg, J.F., Chengappa, K.N., 2009. Identifying and treating cognitive impairment in bipolar disorder. Bipolar Disorders 11 (Suppl 2), 123137.
Golden,C.J., 1978. Stroop Colour and Word Test. Stoelting, Chicago.
Hamilton, M., 1960. A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry 23, 5662.
Heaton, R.K., 1981. Wisconsin Card Sorting Test Manual. Psychological Assessment
Resources, Odessa, Florida.
36
Judd, L.L., Schettler, P.J., Akiskal, H.S., Maser, J., Coryell, W., Solomon, D., Endicott, J.,
Keller, M., 2003. Long-term symptomatic status of bipolar I vs. bipolar II
disorders. International Journal of Neuropsychopharmacology 6 (2), 127137.
Lopez-Jaramillo, C., Lopera-Vasquez, J., Gallo, A., Ospina-Duque, J., Bell, V., Torrent, C.,
Martinez-Aran, A., Vieta, E., 2010. Effects of recurrence on the cognitive
performance of patients with bipolar I disorder: implications for relapse prevention and treatment adherence. Bipolar Disorders 12 (5), 557567.
Martinez-Aran, A., Scott, J., Colom, F., Torrent, C., Tabares-Seisdedos, R., Daban, C.,
Leboyer, M., Henry, C., Goodwin, G., Gonzalez-Pinto, A., Cruz, N., SanchezMoreno, J., Vieta, E., 2009. Treatment non-adherence and neurocognitive
impairment in bipolar disorder. Journal of Clinical Psychiatry 70 (7),
10171023.
Martinez-Aran, A., Torrent, C., Sole, B., Bonnin, C.M., Rosa, A.R., Sanchez-Moreno, J.,
Vieta, E., 2011. Functional remediation for bipolar disorder. Clinical Practice
and Epidemiology in Mental Health 7, 112116.
Martinez-Aran, A., Vieta, E., Colom, F., Torrent, C., Reinares, M., Goikolea, J.M.,
Benabarre, A., Comes, M., Sanchez-Moreno, J., 2005. Do cognitive complaints in
euthymic bipolar patients reect objective cognitive impairment? Psychotherapy and Psychosomatics 74 (5), 295302.
Martinez-Aran, A., Vieta, E., Reinares, M., Colom, F., Torrent, C., Sanchez-Moreno, J.,
Benabarre, A., Goikolea, J.M., Comes, M., Salamero, M., 2004. Cognitive function
across manic or hypomanic, depressed, and euthymic states in bipolar
disorder. American Journal of Psychiatry 161 (2), 262270.
Martino, D.J., Igoa, A., Marengo, E., Scapola, M., Strejilevich, S.A., 2011. Neurocognitive
impairments and their relationship with psychosocial functioning in euthymic
bipolar II disorder. The Journal of Nervous and Mental Disorders 199 (7), 459464.
Miskowiak, K., Vinberg, M., Christensen, E.M., Kessing, L.V., 2012. Is there a
difference in subjective experience of cognitive function in patients with
unipolar disorder versus bipolar disorder? Nordic Journal of Psychiatry.
Mora, E, Portella, M.J., Forcada, I., Vieta, E., Mur, M., 2012. Persistence of cognitive
impairment and its negative impact on psychosocial functioning in lithium-treated,
euthymic bipolar patients: a 6-year follow-up study. Psychological Medicine.
Pallanti, S., Quercioli, L., Pazzagli, A., Rossi, A., DellOsso, L., Pini, S., Cassano, G.B.,
1999. Awareness of illness and subjective experience of cognitive complaints
in patients with bipolar I and bipolar II disorder. American Journal of
Psychiatry 156 (7), 10941096.
Reitan, R.M., 1958. Validity of the trail making test as an indication of organic
brain damage. Perceptual and Motor Skills 8, 271276.
ola
Rey, A., 1997. Test de copia de una gura compleja. Manual adaptacion espan
Madrid. TEA ediciones.
Robinson, L.J., Thompson, J.M., Gallagher, P., Goswami, U., Young, A.H., Ferrier, I.N.,
Moore, P.B., 2006. A meta-analysis of cognitive decits in euthymic patients
with bipolar disorder. Journal of Affective Disorders 93 (1-3), 105115.
Schouws, S.N., Comijs, H.C., Stek, M.L., Beekman, A.T., 2012. Self-reported cognitive
complaints in elderly bipolar patients. American Journal of Geriatric Psychiatry 20 (8), 700706.
Sole, B., Bonnin, C.M., Torrent, C., Balanza-Martinez, V., Tabares-Seisdedos, R.,
Popovic, D., Martinez-Aran, A., Vieta, E., 2012. Neurocognitive impairment and
psychosocial functioning in bipolar II disorder. Acta Psychiatric. Scandinavica
125 (4), 309317.
Sole, B., Martinez-Aran, A., Torrent, C., Bonnin, C.M., Reinares, M., Popovic, D.,
Sanchez-Moreno, J., Vieta, E., 2011. Are bipolar II patients cognitively
impaired? A systematic review. Psychological Medicine, 113.
Svendsen, A.M., Kessing, L.V., Munkholm, K., Vinberg, M., Miskowiak, K.W., 2012. Is
there an association between subjective and objective measures of cognitive
function in patients with affective disorders? Nordic Journal of Psychiatry 66
(4), 248253.
Tabares-Seisdedos, R., Balanza-Martinez, V., Sanchez-Moreno, J., Martinez-Aran, A.,
Salazar-Fraile, J., Selva-Vera, G., Rubio, C., Mata, I., Gomez-Beneyto, M., Vieta, E.,
2008. Neurocognitive and clinical predictors of functional outcome in patients
with schizophrenia and bipolar I disorder at one-year follow-up. Journal of
Affective Disorders 109 (3), 286299.
Torrent, C., Martinez-Aran, A., Amann, B., Daban, C., Tabares-Seisdedos, R.,
Gonzalez-Pinto, A., Reinares, M., Benabarre, A., Salamero, M., McKenna, P.,
Vieta, E., 2007. Cognitive impairment in schizoaffective disorder: a comparison
with non-psychotic bipolar and healthy subjects. Acta Psychiatric Scandinavica 116 (6), 453460.
Torrent, C., Martinez-Aran, A., Bonnin, C.M., Reinares, M., Daban, C., Sole, B., Rosa, A.R.,
Tabares-Seisdedos, R., Popovic, D., Salamero, M., Vieta, E., 2012. Long-term
outcome of cognitive impairment in bipolar disorder. Journal of Clinical Psychiatry
73 (7), e899e905.
Torrent, C., Martinez-Aran, A., Daban, C., Amann, B., Balanza-Martinez, V., del Mar, B.C.,
Cruz, N., Franco, C., Tabares-Seisdedos, R., Vieta, E., 2011. Effects of atypical
antipsychotics on neurocognition in euthymic bipolar patients. Comprehensive
Psychiatry 52 (6), 613622.
Torrent, C., Martinez-Aran, A., Daban, C., Sanchez-Moreno, J., Comes, M., Goikolea, J.M.,
Salamero, M., Vieta, E., 2006. Cognitive impairment in bipolar II disorder. British
Journal of Psychiatry 189, 254259.
van der Werf-Eldering, MJ, Burger, H., Jabben, N., Holthausen, E.A., Aleman, A.,
Nolen, W.A., 2011. Is the lack of association between cognitive complaints and
objective cognitive functioning in patients with bipolar disorder moderated by
depressive symptoms? Journal of Affective Disorders 130 (1-2), 306311.
Videira, D., Balanza-Martinez, V, Soeiro-de-Souza, V., Moreno, M.G., Figueira, R.A.,
hado-Vieira, M.L., Vieta,E., R., 2012. Pharmacological approaches in bipolar
disorders and the impact on cognition: a critical overview. Acta Psychiatric
Scandinavica.
Vieta, E., 2011a. Bipolar units and programmes: are they really needed? World
Psychiatry 10 (2), 152.
Vieta, E., 2011b. Tertiarism in psychiatry:Barcelona clinic Bipolar Disorders
Programme. Revista de Psiquiatria y Salud Mental (Barcelona) 4, 14.
Vieta, E., Gasto, C., Otero, A., Nieto, E., Vallejo, J., 1997. Differential features
between bipolar I and bipolar II disorder. Comprehensive Psychiatry 38 (2),
98101.
Vieta, E., Popovic, D., Rosa, A.R., Sole, B., Grande, I., Frey, B.N., Martinez-Aran, A.,
Sanchez-Moreno, J., Balanza-Martinez, V., Tabares-Seisdedos, R., Kapczinski, F.,
2012. The clinical implications of cognitive impairment and allostatic load in
bipolar disorder. European Psychiatry.
Weschler, D. Weschler Memory ScaleThird Edition. 1997a. Ref Type: Catalogue.
Weschler, David. The Wechsler Adult Intelligence Scale-III (WAIS-III). 1997b. Ref
Type: Catalogue.
Young, R.C., Biggs, J.T., Ziegler, V.E., Meyer, D.A., 1978. A rating scale for mania:
reliability, validity and sensitivity. British Journal of Psychiatry 133, 429435.